Have you read Parts 1 & 2 of our series on this topic?
We elaborated on how hospital admissions and the payment of claims work and also discussed the importance of “relevant” treatment, etc.
In Part 3 of our series will now elaborate on short payments that relate to Scheme exclusions, diagnostic tests and treatment that may not be deemed medically appropriate.
The following conditions, procedures and services are examples of the more common type of exclusions that may be applicable to members. In certain instances some of the costs may be paid from the member’s available savings benefit. It will however not be funded by the Scheme (unless otherwise expressly stated to the contrary in the Rules, or as otherwise determined by the Board).
|Alcohol, solvent or drug abuse, or addiction to narcotic (tranquiliser) substances||Radial keratotomy (surgical procedure to correct nearsightedness)|
|All forms of treatment relating to non-malignant (non-cancerous) skins lesions (e.g. moles, warts, birthmarks), keratosis (horny growth), skin tags, cysts, papillomas (wart-like growth), lipomas (fatty tissue growth), hemangiomata (non-cancerous tumor of blood vessel under the skin)||Sport / hobby or other activity related injuries where reasonably safety precautions were not followed and where, in the opinion of Genesis, such injury created a negligent endangerment of the individual’s wellbeing|
|Breach of law (i.e. driving under the influence)||Attempted suicide or willfully self-inflicted injuries|
|Obesity, scar revision or cosmetic procedures for personal reasons||Costs in respect of conditions that were subject to waiting periods when joining the Scheme|
|Sterilisation (i.e. tubal ligation and vasectomy) / contraception / Mirena device (insertion and / or removal, irrespective the reason)||The cost of medical services rendered outside South Africa|
|Diagnostic tests / examinations that do not result in the diagnosis or confirmation of a condition that requires surgery||Biological or specialised drugs / medication for the treatment of PMBs which are also not available in the State|
|Medication, or the administering of medication to treat non-PMB chronic illnesses and conditions||Treatment of any condition or complication that may arise as a result of any originally excluded treatment or benefit|
|Injuries arising from motorised speed contests, speed trials or the use of quad bikes and the like (unless exemption is granted by the Board)||Conditions which existed at the time of completing the member application form and which were not disclosed|
|Breast reductions / augmentations (enlargement), except in the case of breast cancer, where reconstructive surgery may be authorised at the discretion of the Board||Medical treatment in a research environment and drugs, substances, appliances and the like that are not registered in South Africa, or that are authorised under Section 21 of the Medicines and Related substances Control Act.|
|Treatment / procedures relating to slimming||Educational / remedial / marriage counselling|
|Non-functional nasal reconstruction||Cost of services rendered by persons or institutions not registered with a recognised professional body established in terms of an Act of Parliament|
Please note that the above table provides a summary of the Scheme exclusions. For more detail, refer to Annexure C of the Scheme Rules.
As a rule and unless expressly stated to the contrary, the cost of diagnostic tests / examinations will not be covered unless it results in the diagnosis or confirmation of a condition that necessitates surgery.
All tests done must be directly related to the primary reason for admission to hospital and the funding decision of such tests will ultimately be at the discretion of Genesis. Members cannot be admitted to hospital for the sole purpose of having tests done “because something is / may be wrong”. There has to be a medically appropriate reason (diagnosis) for the admission into hospital, as well as a corresponding treatment plan for that condition. An example is the lady that sought admission to hospital with chest pains and then had an x-ray of her foot that was troubling her. The x-ray of the foot could quite easily be taken out of hospital.
Treatment not deemed medically appropriate
Whilst Genesis will never interfere with how your doctor / specialist treats you, it is possible that the costs of some treatment / procedures may not be covered if, in the opinion of the Scheme, such treatment / procedures are not deemed medically appropriate.
The following examples will demonstrate the application of the concept “medically appropriate”.
- The Scheme will not cover the cost of a procedure if it is principally selected for consideration of comfort or convenience, i.e. choosing to have a caesarian section if there were no foreseeable complication(s) related to giving normal birth.
- Another example is the use of a PCA pump (for electronically controlled infusion of pain medication) for conditions other than major joint replacements, open, upper abdominal surgery, severe burns, intractable pain associated with cancer, or surgery related to the opening of the chest (thoracotomy).
- The Scheme will not cover an expensive alternative if more cost-effective treatment / procedures are available, i.e. performing a laparoscopic appendectomy / hysterectomy vs performing the procedure surgically.
- The Scheme will not cover the cost of in-hospital stay if no rational or reasonable treatment is received in relation to the primary reason for the admission, i.e. simply being in hospital to run diagnostic tests, to be observed only, to receive oral medication only, or to see a doctor / specialist for any condition unrelated to the primary reason for your admission.
For more information on this topic, please contact Genesis on 0860 10 20 10.
Also read Parts 1 & 2 of our series on “Understand funding for hospital admissions”.