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Medical aid glossary

Ex gratia payment

A discretionary payment a scheme may make where there is no benefit entitlement but the circumstances are exceptional. Ex gratia applications are decided by a committee, are not an entitlement, and should not be confused with enforcing a Prescribed Minimum Benefit, which is a legal obligation.

Where you will see this term

Terms like this appear on claims statements, remittance advices, authorisation letters and scheme rules. Understanding the exact wording your scheme used is usually the first step in working out whether a rejected or short-paid claim can be disputed.

Browse the full glossary.

Related terms

Above Threshold Benefit (ATB)Annual limitAuthority to actBeneficiaryBenefit yearCase managerChronic Disease List (CDL)Chronic medication list (formulary)Chronic registrationClaims shortfallClaims statementClinical motivation

Claim review

Not sure what your scheme's wording means for your claim?

Send us the rejection letter, the itemised account and the clinical notes. We translate the scheme's reasoning into plain English and tell you whether the decision stands up against its own rules and the Prescribed Minimum Benefit regulations.

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This page is provided for general information and does not constitute legal or medical advice. Medical scheme rules, benefit structures and regulations change over time — always confirm the position with your scheme’s current member material, your treating practitioner, or an attorney admitted in South Africa.

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