How much do you spend on your medical aid scheme payments, and how does it help you in the case of an emergency?
For younger, healthier members, you may not have been in an emergency situation; however it is still comforting to know that if something were to happen to you or a family member, you will be covered.
You do not want to be rushed off to a private hospital, only to discover that your medical scheme will not cover the bill. To make sure you have a clear understanding on what constitutes an emergency, we have answered the following important questions for you.
1. Do all South Africans have a right to emergency medical treatment?
Section 27(3) of the SA Constitution states the following:
“no one may be refused emergency medical treatment”.
When a person does not have a scheme, in the case of an emergency, they will usually be sent to a government hospital for health care. Unfortunately, government hospitals in South Africa have been continuously regressing.
But, who pays for the bill if a person, who has no medical aid scheme or the ability to finance the bill, ends up at a private healthcare facility? Usually, these patients will be transferred to government hospitals once stabilised.
2. What is qualified as a medical emergency?
Medical Schemes Act of 1998 explains an emergency:
“An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.”
By mentioning the word “sudden”, it eliminates expected long-term consequences of injuries or organ damage; for example, damage to the heart or lungs caused by adverse effects of an operation. This means that, to get emergency treatment, long-term consequences in which treatment was not obtained will have to be foreseen. For certain medical issues, you will have to go see your GP before heading to the trauma unit.
3. Do I have to pay for the ambulance services?
If you have a medical aid scheme, your trip to designated service provider (DSP) facilities is likely to be covered. Schemes may not, however, pay for transfers that are not necessary; for example, if you decide you want to go to a specific hospital, based on personal choice, you may have to pay for the ambulance services out of your own pocket.
Also, the scheme will not fund your ambulance fee if you are excluded from specific treatment for the first few months to a year of joining a new scheme.
State ambulances are usually free, but, for employed people, they may still send a bill; this is, however, significantly cheaper than private ambulances.
4. What happens if I am in an accident and cannot contact my medical scheme?
The staff at the hospital will contact your scheme, notify them of your accident and obtain all relevant information from your scheme.
5. Do I have to use a DSP?
In a life-threatening situation, you will be treated at the nearest facility, regardless of if it is a DSP or not. Once you are stabilised and safe to be moved around, you will be sent to a DSP.
If you are not in a life-threatening situation, yet still want to use a non-DSP, you will have to make a co-payment of the bill with your medical aid scheme, paying the amount over and above what the medical scheme is willing to pay.
6. Is there situations where my scheme may not cover my medical expenses?
Yes, if you are not admitted into an emergency room due to the fact that your condition is not serious enough, or if your condition is not on one of the Prescribed Minimum Benefits (PMS) of your medical aid scheme, you will have to pay for the medical bill out of your own pocket.
The above information is not set in stone and changes according to the Medical aid scheme. Find out more about medical aid and hospital cover.
Read more:
http://www.fin24.com/Money/Health/when-is-a-medical-emergency-an-emergency-20160914
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