Overview

Once we confirm your hospital admission, we may not pay for the treatment in full. Your cover is according to the Fund’s rules, funding guidelines and clinical rules.

There are some expenses you may incur while you are in hospital that the Hospital Benefit does not cover, for example private wards. Certain procedures, medicines or new technologies need extra benefit confirmation while you are in hospital.

We only pay for medically appropriate hospitalisation

We pay only medically appropriate claims from the Hospital Benefit.

Your healthcare professionals’ accounts are separate from the hospital account. Healthcare professional accounts may include specialist accounts and other related accounts, for example accounts from a:

• surgeon,
• anaesthetist,
• pathologist or
• radiologist.

Healthcare professionals are free to set their own rates:

• If they charge the Fund Rate, we will pay them directly.
• If they charge more than the Fund Rate, we will pay you. You will be able to see this on the claims statement we send to you. You will have to make sure you pay your healthcare professionals the full amount.
• If your specialist is part of the Custom Direct Payment Arrangement network and charges the agreed rate, we will pay the specialist directly.

We cover the cost of specialists who are on the Custom Direct Payment Arrangement network and charge the agreed rate

If you use specialists who charge the agreed rate, you will not have to pay from your pocket the difference between what the specialist charges and what we pay for procedures and consultations. You will always be charged at the Fund’s agreed rate if you use a specialist that is part of this network. To find out if your specialist charges the agreed rate, you can contact us.

We may pay you

If your doctor charges higher than the Fund Rate, we will pay you up to the Fund Rate and you will be responsible to pay the full amount to the doctor directly.

You have a basic level of cover for serious medical conditions. According to the Prescribed Minimum Benefits, in certain circumstances you have the right to get a minimum level of cover for a list of medical conditions and treatments in terms of legislation. The medical scheme must pay for these benefits even if your benefits have run out or you are in a waiting period. These benefits include cover for a list of 271 listed conditions, most emergency conditions and 27 listed chronic conditions that include HIV and AIDS. Medical schemes must provide cover for the diagnosis, treatment and costs of the ongoing care of these conditions.

To access Prescribed Minimum Benefits, certain rules apply:

• Your medical condition must be part of the list of defined conditions for Prescribed Minimum Benefits.
• The results of your medical tests and investigations must match the requirements for diagnosis of your medical condition.
• The treatment you need must match the treatments listed in the Prescribed Minimum Benefits as appropriate for your medical condition.
• You must use a doctor, specialist or healthcare provider in the Fund’s network. This does not apply in life-threatening emergencies. However, even in these cases, you must get to a healthcare provider in the network as soon as possible – otherwise you may be responsible to pay part or all of the treatment costs yourself.

It is important to remember the Prescribed Minimum Benefits only provide the minimum level of cover. You have richer benefits available on the N Option Plus and N Options Basic.

Find out more about how we pay for Prescribed Minimum Benefits.