When does your medical aid cover the cost of a visit to the Emergency Centre at a private hospital?
It’s a Sunday afternoon and your three-year-old toddler has a high fever and is vomiting. You cannot get hold of your GP, as his practice is closed over weekends. You are very worried and is desperate to have her seen to by a doctor.
Or you get a call from the school… your son has possibly dislocated his shoulder during his rugby practice. He is in excruciating pain and you must fetch him and take him to the doctor immediately.
The shock – no cover from your medical aid
Yes – we have all been there. An “emergency situation” arises and we need to see a doctor rather urgently. We rush to the Emergency Centre of the nearest private hospital, because we belong to a medical scheme, but then… the medical aid doesn’t pay any of our claims! And we are left stunned, angry and frustrated.
Some people get so angry that they revert to Hellopeter, or they resign from their “useless” medical aid.
Emergency Centres don’t belong to private hospitals
So – how does it really work? When does your medical aid scheme cover the cost of a visit to the Emergency Centre at a private hospital, and when don’t they?
The emergency rooms at private hospitals are not owned by the hospitals. Instead, they are owned by private practicing doctors. Although this practice may be right next to the hospital, or even attached to the hospital, it is in no way part of the hospital.
How are patients treated?
Where appropriate, patients are treated by the doctors (or nurses) at these Emergency Centre facilities. Treatment can vary in time, i.e. it can be a quick in-and-out visit, or the patient may be kept there for a few hours. The treatment may include for example a consultation (with or without a prescription), doing diagnostic tests (e.g. blood tests, X-rays, ECG, etc.), the stitching of an open wound and the splinting of a limb, to name but a few.
Irrespective how serious or traumatic a visit to the Emergency Centre may have been, if treatment was not related to a medical emergency or a PMB and the patient is then sent home again, he / she were never admitted into hospital. As a result, such a visit is in essence the same as a visit to your GP’s rooms. To this end, treatment or services received, e.g. blood tests, X-rays, stitches, drip, medication, etc. will only be covered from the member’s out-of-hospital benefits, i.e. a medical savings account. It does not qualify for in-hospital benefits on your medical aid.
When patients are admitted to hospital
If, however, in the opinion of the treating doctor at the emergency practice, the patient cannot be treated at the emergency practice and when clinically or medically appropriate, the patient may be admitted into that hospital (provided that the patient is a member of a medical aid scheme or is able to pay a deposit prior to admission). Once admitted to hospital, the patient will then receive medically appropriate treatment and his / her medical scheme will fund such treatment in line with the in-hospital benefits he / she has.
Medical schemes are not in the wrong
From time to time medical schemes are accused of being a rip-off, being heartless or being money-hungry “crooks” when they decline a benefit, or don’t settle a claim in full or at all. The simple truth of the matter is however that claims are rejected, or short paid, because the rules of the scheme are being applied. No benefits may exist outside of the scheme rules.
The Medical Schemes Act forces schemes to apply their registered rules. Whether members like it or not, membership of a medical scheme is on the basis of a legal contract and medical schemes are not companies taking members’ money.
Know your medical aid benefits
Unfortunately, it sometimes takes a very worrying and traumatic situation before one takes notice of what it is that you in fact have in the way of benefits.
Make sure that you understand your medical aid benefits. If you are on a hospital plan, then a normal visit to the Emergency Centre will usually not be covered by your medical aid. If you are on a benefit option with medical savings, such a visit may be covered from your available savings or Self Managed Fund or other day-to-day or specified benefits. Bear in mind that benefit options with out-of-hospital benefits will undoubtedly have higher monthly contributions. Benefits and contributions go hand-in-hand; so weigh up your options and choose wisely.