How Medical Aids Treat Emergencies

If you undergo emergency treatment, your medical aid should be obliged to cover the total cost involved.

However, in the real world things don’t often work out this way. That’s because it can cost a considerable amount to diagnose a patient’s condition in an emergency.

While the Medical Schemes Act obliges medical schemes to cover, the medical costs associated with a medical emergency, which is one of the 26 Prescribed Minimum Benefits (PMBs) that medical schemes supply, in reality the medical aids often do not pay what they should.

If you land up in an emergency room or trauma unit and then you are sent to hospital, your costs will generally be paid. However, if your condition turns out to be less serious than initially supposed then you might find yourself under serious financial strain.

This is because emergency room fees and diagnostic tests could amount to thousands of rands which, your medical aid might insist, should be paid from your day-to-day benefits – a medical savings account, for instance.

An Example of How a Medical Aid Can Treat an Emergency

Take for instance Mrs S, an elderly woman in Durban, who felt a pain in her chest. The nursing sister in the retirement village where Mrs S lived immediately called an ambulance, and Mrs S was taken to an emergency room at a private hospital. The medical staff conducted tests on her and a cardiologist was summoned, who conducted an ultrasound scan and fitted a device to track her pulse for three days. That meant three days in hospital.

Eventually, the cardiologist found that her heart was perfectly healthy.

Emergencies and Medical AidsA few days after she was discharged, Mrs S began to receive medical bills – about R1 000 for the emergency room, R500 for the pathologist and a hefty R3 000 for the cardiologist. Mrs S phoned her medical aid, who told her that they would pay nothing at all from their risk fund. Her medical savings would have to pay for it. This meant that she had nothing left in the savings account for the rest of the year and the outstanding amount (the savings account did not cover the full amount) would have to come out of her pocket.

There have been several similar instances over the years in South Africa and these cases have ended up in arbitration with the Council for Medical Schemes. Usually the outcome has been in favour of the medical schemes, simply because the medical aid member was not familiar with the conditions and the small print associated with his or her medical scheme option.

How to Treat Medical Aids and Emergencies

So what should you do? You should make sure that your medical aid has casualty cover. Ask your medical scheme or insurance broker to ensure that you would be covered in an instance such as this.

For example, Liberty Medical Scheme includes a casualty benefit on most of its options. This means that the kind of expenses as those occurring above – such as ambulance, facility, specialist consultations, CT scans, x-rays, medications, radiation and pathology – would NOT be paid out of a medical savings account.

Also, if at all possible, you should contact your medical aid as soon as you are in casualty so that they can monitor the situation.