Money

Learn about what in­juries can be taken to ca­su­alty

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OUCH! You’re run­ning down a flight of stairs and next thing you know you’re ly­ing on the floor. From the pain you’re feel­ing you know that a visit to ca­su­alty is on the cards – you sus­pect you might have a bro­ken arm and also, based on how your head is throb­bing, pos­si­bly a con­cus­sion.

The way you see it, this is a med­i­cal emergency – so surely it will be cov­ered by your med­i­cal aid? Ac­tu­ally, it’s a bit more com­pli­cated than that.

WHEN IS IT AN EMERGENCY?

The Med­i­cal Schemes Act de­fines an emergency as a sud­den, un­ex­pected med­i­cal con­di­tion that requires im­me­di­ate med­i­cal treat­ment or surgery.

If this treat­ment isn’t avail­able, it can lead to im­paired bod­ily func­tions; se­ri­ous, last­ing dam­age to or­gans or other body parts; or death.

The core of the con­cept is that in­juries or con­di­tions must be life-threat­en­ing or lifechang­ing to be con­sid­ered a pre­scribed min­i­mum ben­e­fit (PMB), which med­i­cal aids must cover by law, says Deon Hey­den­rych, a med­i­cal-aid bro­ker at Se­cure My Fu­ture.

WHAT ARE EX­AM­PLES OF PMB EMER­GEN­CIES?

These include some­one who’s been in a car crash and their or­gans are dam­aged or they’re bleeding in­ter­nally.

Or it could be some­one who is al­ler­gic to bee stings and was stung and is now strug­gling to breathe.

On the other hand, bro­ken bones, wounds that need stitch­ing, non-se­ri­ous head in­juries or bruises aren’t con­sid­ered med­i­cal emer­gen­cies in terms of PMBs.

If you fall, suf­fer a con­cus­sion, and have a pos­si­ble skull frac­ture, it would be ­re­garded as a con­di­tion that requires emergency treat­ment and so all tests (X-rays, CT scans) for this type of head in­jury would be cov­ered – even if it turns out you don’t have a skull frac­ture.

But if the con­di­tion is ruled out and you’re treated for some­thing else in ad­di­tion that isn’t clas­si­fied as a PMB – for in­stance a bro­ken arm – it will be processed by your med­i­cal aid ac­cord­ingly.

HOW ARE LESS-SE­RI­OUS AC­CI­DENTS COV­ERED?

Pay­ment for patients treated in the emergency unit, but who aren’t ad­mit­ted to hospi­tal, usu­ally comes out of day-to-day or sav­ings benefits.

Hey­den­rych says there are cer­tain med­i­cal aids that will cover emergency-unit treat­ment, but only if there is trauma.

HOW WILL YOUR FUND PAY OUT?

If it’s a PMB, your med­i­cal aid will pay the full claim – but there might be terms and ­con­di­tions. For ex­am­ple, if you’re on a net­work plan, your med­i­cal aid might in­sist that a net­work hospi­tal be used.

In a life-threat­en­ing sit­u­a­tion, the am­bu­lance will take you to the near­est hospi­tal.

You’ll be sta­bilised there and then your med­i­cal aid will have you trans­ferred to a net­work ­hospi­tal, Hey­den­rych ex­plains.

But if you have com­pre­hen­sive med­i­cal cover you can get full treat­ment from the first hospi­tal you’re taken to.

HOW DOES AU­THO­RI­SA­TION WORK?

All med­i­cal aids re­quire au­tho­ri­sa­tion for in-hospi­tal pro­ce­dures, even emer­gen­cies. But in an emergency, it can be hard to get pre-au­tho­ri­sa­tion.

You might not have your mem­ber­ship de­tails with you, or you might not be phys­i­cally ca­pa­ble of pro­vid­ing it.

Paramedics will try to esta­blish if you’re a med­i­cal-aid mem­ber by look­ing in your ve­hi­cle or wal­let. In these cases, au­tho­ri­sa­tion can be ob­tained by a fam­ily mem­ber or hospi­tal staff.

Funds sim­ply re­quire that it hap­pens within a cer­tain time pe­riod, such as the first work day af­ter the in­ci­dent, or within 48 hours, Hey­den­rych says.

WILL YOU HAVE TO PAY BACK THE MONEY?

By law, med­i­cal aids may ex­pect a mem­ber to pay back the money if the patient is also com­pen­sated by a third party.

This is to pre­vent any­one from get­ting du­pli­cate com­pen­sa­tion.

For ex­am­ple, if you’re in a car crash and your med­i­cal aid cov­ers your treat­ment, but you also suc­cess­fully claim from the Road Ac­ci­dent Fund, most med­i­cal aids will ex­pect you to pay back the claim.

WHAT CAN YOU DO IF YOUR MED­I­CAL AID DOESN’T AGREE THAT IT WAS AN EMERGENCY?

Firstly, complaints must be lodged with the fund. If you have a med­i­cal-aid bro­ker, they can help you with this.

If you’re still not sat­is­fied with the fund’s an­swers, you can lay a com­plaint with the Coun­cil for Med­i­cal Schemes (see be­low).

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