|Why are my limits calculated on a pro-rata basis?||If you haven’t been a member of Medihelp Medical Scheme from 1 January, then the annual benefits to which you’re entitled are adjusted pro rata, relative to your period of membership in the year of the services rendered.|
|Are all emergency visits to emergency units covered from the benefits for emergency services?|
Not necessarily. Only emergencies which meet the definition of an emergency medical condition, as defined in the Medical Schemes Act No. 131 of 1998, are covered by Emergency Services Benefits.
Emergency medical conditions are subject to the following:
- The onset of the health condition must be sudden and unexpected
- It must require immediate medical or surgical treatment
- Failure to provide such treatment would result in serious impairment to bodily functions; serious dysfunction of a bodily organ or part or would place the person’s life in serious jeopardy
- It must be certified as such by a medical practitioner.
Emergencies qualify for Prescribed Minimum Benefits (PMB) and must therefore also be registered for PMB.
Any visit to an emergency room or emergency medical unit which does not conform to these requirements will receive the normal benefits available for doctors’ consultations. Emergency units at most hospitals are a separate practice to the hospital and the doctors at the emergency unit will decide whether a patient must be admitted to hospital.
|Does Medihelp have a hospital plan?||All Medihelp’s benefit options offer comprehensive benefits for hospitalisation, in addition to other benefits. However, if you need a hospital plan only, have a look at the Dimension Prime 1 benefit option. In addition to benefits for hospitalisation, we also offer preventative care benefits. This provides for certain services focused on the early detection and prevention of common medical conditions.|
|What will happen if I do not pre-register my admission to hospital?||If you don’t pre-register your hospital admission, you will have to pay a penalty fee! This fee is equal to 20% of the benefit amount of the hospital account payable by the member if the medical condition is not a benefit exclusion in terms of the Medihelp Rules, in which case the total account will be excluded from benefits. Emergency admissions must be registered on the first working day following the admission. This can be done by the member, a relative, the hospital or attending doctor.|
|What if I am hospitalised after-hours for a medical emergency?||You will still need to register your admission. Simply contact Medihelp on the first working day following your admission. |
|Some of my benefits are ‘pooled’. What does that mean?||This means that the benefits available to each beneficiary are added together (pooled). This total amount may be used by any beneficiary.|
|What does Medihelp consider to be Chronic Medicine?|
Chronic Medicine is used to treat chronic diseases; that is, long-term treatments (three months or longer) of a chronic condition which meets the following requirements:
- The medicine is used to prevent a serious medical condition
- The medicine is used for an uninterrupted period of three months or longer
- The medicine is used to sustain life, delay the progress of a disease and/or to repair natural physiology
- The medicine is registered in South Africa for the treatment of the medical condition for which it’s prescribed
- The medicine is the accepted treatment, according to local and international treatment protocols and algorithms.
- Benefits for chronic medicine differs between the various Medihelp products.
|Does Medihelp grant benefits for services not mentioned in the Rules or in the benefit brochures (ex gratia benefits)?||No, we do not. Medihelp’s benefit options are registered by the Registrar of Medical Schemes and form part of the Rules of Medihelp, which are also approved and registered by the Registrar. As the Rules are binding on all members, the Scheme cannot and may not grant benefits for any service not covered by the particular benefit option.|
|Should I make use of designated service providers (DSPs) if I am on one of the Dimension Prime network options?||Yes, members of the Dimension Prime network benefit options should make use of network hospitals for planned procedures and network providers for registered PMB chronic as well as oncology medication.|
|What happens if I am on a network option and I am admitted to a non-network hospital?||Medihelp will pay 65% of the hospital account’s benefit amount in the case of voluntary admission to a non-network hospital.|