Planned operations
Cover for planned hospital admissions
Before you go to hospital for any planned procedure, you must:
- See your doctor
- Check whether your specialist participates in the network
- Call us on 0860 627 633 to confirm your hospital admission at least 48 hours before you go to hospital. If you do not preauthorise your benefits, we will not pay for the costs that we would normally cover.
When you contact us, give us the following details:
- Your membership number
- When you will be admitted to hospital and how long you will stay
- The date of the procedure
- The name of the hospital or clinic
- Your treating doctor’s name, practice number and phone number
- Your diagnosis (ask your doctor for the ICD-10 diagnosis code)
- The procedure name (ask your doctor for the CPT or RPL procedure codes).
- If one of your dependants is admitted, give us their details.
Cover is subject to our rules
We pay medically appropriate claims. Your cover is subject to the Fund’s rules, funding guidelines and clinical rules.
There are some expenses that you may incur while you are in hospital that your Hospital Benefit does not cover, for example private ward costs. Certain procedures, medicines or new technologies need separate approval while you are in hospital.
Cover for Prescribed Minimum Benefits
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 Fund must pay for these benefits even if your Benefit Option’s 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. The Fund must provide cover for the diagnosis, treatment and costs of the ongoing care of these conditions.
To access Prescribed Minimum Benefits, there are certain rules that 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 other healthcare provider in the network. This does not apply in life threatening emergencies. However, even in these cases, once your condition stabilises you must access a healthcare provider in the network as soon as possible – otherwise you may be responsible to pay part of the treatment costs yourself.