Emergencies

What is a medical emergency?

A medical emergency is defined in the Medical Schemes Act as “the sudden and unexpected onset of a health condition that requires immediate medical and/or surgical treatment, where failure to provide such treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy”.

Does Medihelp cover medical emergencies?

Yes. If you require treatment at an emergency unit for a medical emergency as defined in the Medical Schemes Act, the doctor who treats you will certify the condition as a medical emergency and Medihelp will approve it as a prescribed minimum benefits (PMB) condition.

How do I register an emergency hospital admission?

Emergencies must be registered on the first workday after the admission. Phone Medihelp's Customer Care centre on 086 0200 678. Remember to have the following information at hand:

• Membership number
• Details of the patient, hospital and doctor
• Diagnostic and procedure codes
• Admission date and time

What happens if my condition does not qualify as a medical emergency?

If you visit an emergency room and you don’t require life-saving treatment and/or admission to hospital after the ER doctor has examined you, the treatment you receive will be viewed as a visit to a GP’s emergency room and not as a medical emergency. Medihelp will then cover the consultation fee from the available benefits of your medical aid plan. Any facility fees that the emergency unit may charge, will not be covered.

Why does the emergency unit charge facility fees?

Although emergency units are usually situated at hospitals, they do not form part of the hospital. Emergency units are owned by general practitioners and therefore operate like private practices that remain open after hours. Services received at an emergency unit are therefore regarded as regular GP services.

Will I be liable for facility fees charged by the emergency unit?

If your condition does not qualify for PMB, you will be billed for a normal consultation as well as additional fees, such as facility fees and/or after-hours fees which the doctor on call might charge. Medihelp will pay the consultation from your plan’s benefits for consultations, but you will be responsible for the additional fees. If you have no benefits available for consultations, you will also be responsible for the consultation fee.

Will my medical aid plan cover any medication prescribed at the ER?

Registered, regular chronic medicine obtained from an ER will be paid from the chronic medicine benefits available on your benefit option.

Acute medicine will be paid from your acute medicine benefits as set out in your benefit guide. Medihelp pays –

• 100% of the Maximum Medical Aid Price (MMAP) if generic medicine is used
• 80% of the Medihelp tariff (MT) if original medicine is used when no generic medicine is available
• 70% of the MMAP if original medicine is voluntarily used although generic medicine is available

Medicine will first be paid from the savings account and then from the available day-to-day or acute medicine benefits.

Medicine must be obtained from a network pharmacy and will be paid from the available day-to-day or acute medicine benefits.