Article provided by Medshield
You woke up this morning feeling a little off. At first you attributed the stomach pains to the spicy food of the previous night but when the symptoms rapidly become worse, you realised that it must be food poisoning. It is Sunday and your medical service provider is not available on Sundays. A trip to the emergency room seems to be the best option. Will your medical aid pay the costs?
You need to determine if it is really an emergency and, in that case, review the terms and conditions of the emergency room cover of you specific benefit option/plan for your particular medical aid. The Medical Schemes Act of 1998 governs all medical aid service providers in South Africa. According to the Act, an emergency condition is a condition that you experience suddenly and did not expect. It is a condition requiring immediate medical intervention to prevent the body from suffering serious and long-term, or permanent, damage.
“Suddenly” means that it is thus not something that happens gradually. If you have had the condition for two weeks and decide that it is time to visit the emergency room, it is not sudden. If the condition can be treated the next day without your body suffering serious harm because of the delay, it is not an emergency.
Another question often asked is whether the typical South African medical aid will pay for the services of an ambulance. Here too, you should review the terms and conditions of your plan offered by your medical aid. If unsure, rather ask before you assume. In most instances, your South African medical aid will pay for emergency ambulance transportation and even for transfers between designated service providers (DSPs). However, such transfers must be medically necessary rather than because of your preference.
You can therefore not use the ambulance transfer service for your convenience just because you prefer to be at the hospital closest to your home. If the medical facility is unable to provide the medical service you need for the particular health condition, or does not have the equipment to do so, a transfer to one of the DSPs that can provide the required care may be needed. Of course, it is still important to get pre-authorisation from your medical aid.
It is also essential to remember the waiting periods applicable, if any, if you happen to be a new member of a medical aid. To avoid any misunderstandings regarding what your medical aid offers within the borders of South Africa, read through its terms and conditions, review your benefit guide/brochure of your specific plan and the list of PMBs, which the medical scheme must cover. If you are unsure, rather contact the scheme to get clarification prior to engaging the service.