Learn about what injuries can be taken to casualty
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).