What would typically qualify as hospital/major medical expenses?
In contrast to day-to-day medical healthcare needs such as visiting a doctor or a dentist, there are sometimes medical events that are more serious and costly. These would be, for example, surgical procedures, rehabilitation after a car accident, treatment for cancer and other medical treatments that most people would struggle to pay for, if they do not have medical aid. It is in terms of these costs that medical aids offer members the most peace of mind.
Not all these services take place in a hospital – for example, in-rooms procedures such as colonoscopies, and many of the expensive treatments for cancer (under the oncology benefit) take place out of hospital.
On the other hand, just because you are obtaining a medical service inside a hospital building (for example, visiting the Emergency Rooms (ER), or the pathologists), does not mean that such a service will be covered in terms of your hospital benefits, as it may form part of your dayto- day benefits, instead. (A visit to the emergency rooms [ER] that is of a serious nature and results in admission to hospital would qualify under hospital/major medical benefits.)
This chapter outlines the hospital/major medical expenses covered by the Society.
How can I avoid spending unnecessary money on hospital/major medical costs?
- Use one of the Society’s Network Hospitals for procedures to enjoy higher cover. See further down for more about how Network Hospitals will save you money.
- Make sure that any hospital admissions are preauthorised.
- If you need a procedure that can be done either in a GP’s or specialist’s rooms or in hospital, opt for an in-rooms procedure, as a number of procedures are covered at the higher Scheme Rate if performed in the rooms rather than in hospital. See further down for more information.
What are Network Hospitals, and why should I use them?
- A Network Hospital is a DSP with which the Society has negotiated and agreed rates*.
- The Society has DSP arrangements with several hospitals throughout Southern Africa.
- Members using such hospitals will not be liable for hospital co-payments, except where co-payments are noted (for diagnostic arthroscopy, for example).
- Members are encouraged to always make use of Network Hospitals, as failure to do so will result in the member being liable for co-payments.
*Please note that the agreed rates only relate to hospital costs. Co-payments may apply to claims by other service providers (physician, physiotherapist, etc.) while in hospital.
Hospital and Service provider benefit payments in a Network Hospital
- The hospital claim will be paid at the negotiated rate.
- Service providers (Specialist, GP, Anaesthetist, etc.) will be paid at Scheme Rate.
- The Scheme Rate means the rate at which the Society pays benefits to all service providers for services rendered in Network Hospitals. The Scheme Rate is limited to 165% of the SRPL rate.
- Where service providers charge more than the Scheme Rate, the member will be responsible for paying the difference between the benefit provided by the Society in terms of its Rules and the claimed amount.
- Members are encouraged to ask service providers what their charges will be, before undergoing any test or surgery.
- Such excess will be debited to the member where adequate member credit is available.
Hospital and Service provider benefit payments in a NON-NETWORK Hospital
- The hospital claim will be paid at the lower SRPL rate and co-payments will apply
- Service providers (Specialist, GP, Anaesthetist, etc.) will be paid at the lower SRPL rate, should the provider charge the SRPL rate the claim will be paid in full by the Society.
- Should Service providers charge more than SRPL, the member will be liable for the co-payment.
- Ask the doctors/service providers what they will charge in comparison to the SRPL rates, negotiate with all your service providers to charge the SRPL rate if they quote a higher rate. If you are not successful, consider using a Network Hospital as you will be personally liable for all the additional costs over and above the SRPL rate.
- Such excess will be debited to the member where adequate member credit is available.
- You can obtain more information on SRPL rates from the Society on 053 807 3111 (Call centre option 5).
Overcharges by providers
Where a provider overcharge is identified as excessive by the Society, the Society will pay only its liability directly to the Service Provider (benefit due) and the member must settle the difference directly with the service provider.
Members are encouraged to check their weekly/monthly statements to identify whether a service provider has been paid in full by the Society or whether they are required to pay the service provider directly.
Hospital benefits in other facilities
Pre-authorised admissions to day clinics, step-down facilities and other forms of care are not impacted by the above restriction regarding admissions to non-Network Hospitals, and payments to these service providers will be at the Scheme Rate. Co-payments may however still apply under certain circumstances, for example an admission for a day procedure that converts to an overnight stay in a non-Network Hospital or providers charging more than the Scheme Rate.
Psychiatric benefits
Network or Registered Psychiatric Admissions – The treating providers will be paid at Scheme Rate and the hospital at negotiated rates.
Non-Network Admissions – The treating providers and the hospital will be paid at SRPL rate.
How does pre-authorisation work?
Pre-authorisation should be obtained at least five working days prior to the date of service (for example, hospital admissions, CT scans, oncology treatment, procedures, or wheelchairs) by contacting the Society’s relevant pre-authorisation department – see contact details. Where an admission has not been pre-authorised in the case of a pre-planned non-emergency admission, a 30% co-payment will be levied on the total hospital account.
In the case of emergency hospitalisation, the Society must be notified within 24 hours or on the first working day after such admission.
Any associated treatment or procedures performed during hospitalisation must also be pre-authorised.
What if the procedure can be done in the doctor's rooms?
No authorisation is required for minor (non-booked) in-rooms procedures, but please contact the Society’s claims department if you require clarification.
See What are the hospital/major medical benefits and benefit limits for 2021? for more information on the procedures typically covered and that require pre-authorisation.
How do benefits for day procedures work?
If an admission to a non-Network Hospital for a day procedure subsequently results in an overnight stay, the entire account will change from the Scheme Rate to the SRPL rate and the member will be liable for any difference in costs between that charged for a day admission and the actual final account rendered, based on the actual time and date of discharge.
Members are encouraged to ensure that, if they are admitted for a day procedure in a non-Network Hospital, their doctor performs the procedure early enough on the day in question. This will ensure that an overnight stay is not required due to the need to recover from the anaesthetic administered or for any other purpose and will thus avoid any additional co-payments being applied.
What are Managed-care protocols?
Many of the benefits in the table that follows are subject to managed-care protocols. Managed-care protocols are strategies employed by medical schemes and their health-care service providers to offer appropriate benefits to members in a cost-effective way. These include, for example, having medicines lists, requiring preauthorisation before certain procedures or admission to hospital, setting certain financial limits up to which the scheme will pay, or prescribing certain treatment ‘recipes’ that healthcare providers should follow for specific conditions; based on evidence-based medicine.
What are the benefits and benefit limits for hospital/major medical benefits for 2022?
See the table that follows. Unless otherwise specified, limits in this table are per beneficiary per benefit year.
If you are uncertain about any of these benefits, and would like to find out more, please call 053 807 3111 (Option 5).
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GP and specialist in-rooms procedures |
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Hospitalisation (including day cases, fixed-fee cases for cataracts, in-rooms procedures instead of hospitalisation, and alternative facilities) |
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Professional fees charged by service providers in hospital |
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Physiotherapy, occupational therapy, speech therapy and dietician |
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Pathology |
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Radiology (other than CT and MRI Scans) |
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CT and MRI Scans |
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Hospital medicines |
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Home confinement or natural birth delivery |
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Delivery in hospital |
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Corneal transplants |
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Cataract removal |
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Intra-ocular lenses |
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Refractive surgery |
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Maxillofacial and oral surgery |
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Psychiatric hospitalisation (including alcohol and drug dependency in-hospital rehabilitation) |
For both admissions above the following will apply:
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Private nursing |
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Wound care |
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Hospice care |
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Treatment in and out of hospital |
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PET and related CT planning scans |
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Internal prosthesis |
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Renal dialysis (applicable to PMB-confirmed cases only) |
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Organ transplants (applicable to PMB-confirmed cases only) |
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Cochlear implants |
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Blood transfusion |
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Other Benefits
