Concerns Regarding POLMED Medical Scheme

The following claims have been declined as Prescribed Minimum Benefit (PMB) as the primary ICD10 code submitted on the claims is not a PMB diagnosis and there you have it!!! if you considered polmed for medical care think twice.

My recent experience with POLMED under the Aquarium package has revealed troubling gaps between promised benefits and actual support.When my daughter sustained an ankle injury, her doctor recommended diagnostic imaging (X-rays and an ultrasound). Despite the clear medical need, POLMED declined the claim. Their reasoning was that the diagnosis — classified as a sprain — did not qualify as a Prescribed Minimum Benefit (PMB) condition.This decision illustrates a deeper issue: coverage is determined less by clinical judgment and more by rigid administrative coding. Even when a healthcare professional identifies the necessity of further investigation, members may be denied access to essential services simply because the condition doesn’t fit POLMED’s predefined categories.POLMED’s response to my appeal only reinforced this concern. They stated that the claims were declined because the ICD10 code submitted was not a PMB diagnosis. In other words, the scheme’s focus was on paperwork rather than patient care. The suggestion that the diagnosis could be amended for reassessment — without any guarantee of payment — places members in an uncomfortable position of navigating bureaucracy instead of receiving straightforward medical support.A medical aid should provide reassurance in times of need. Instead, this experience highlights a system where members must fight through technicalities to access care.Key Takeaways

• Rigid benefit rules: Coverage depends on coding, not medical necessity.
• Administrative burden: Members may be asked to resubmit or amend diagnoses with no cer*****y of approval.
• Gap in support: The scheme’s processes prioritize compliance over patient well-being.

Final ThoughtProspective members should carefully evaluate whether POLMED’s benefit structure aligns with their expectations for accessible, responsive healthcare. If you value straightforward support during medical emergencies, you may want to think twice before joining.