All Medical aid Options would include: Accidental or emergency medical hospitalisation, maternity benefits, chronic illness benefits, oncology benefits, mammogram screening (once every 2 years), pap smear screening (once every 3 years), and prostate cancer screening (once a year). Below we detail each cover and how it works. Hospitalisation Whether your medical aid option is a hospital plan or a savers plan, as long as you are hospitalized in South Africa and obtain the hospitalization pre-authorization, you are covered. In case of emergency hospitalization, the hospital will contact the Medical aid company directly and obtain authorization When hospitalized, the hospital bill and the doctors’ bills are separate. In the case of elective hospitalization (planned procedure), the Medical Aid company will pay the hospital bill in full (in most of the cases). In terms of doctor's fees, medical aid company will pay according to the scheme rate. For example, if the scheme rate for a certain operation is R5,000, but the doctor can decide how much to charge. If the doctor charges R15,000, the Medical Aid company will only pay R5,000, and the remaining R10,000 is your liability. If you have Gap Cover, the the co-payment can be claimed back. If the patient is hospitalized due to an accident, an emergency or critical illness (such as cerebral hemorrhage), the doctor does not charge more than scheme rate, and the Medical Aid company will pay for the medical cost, and this is unlimited. In addition to applying for pre-authorization for hospitalization, you can also apply for pre-authorization with the Medical Aid company if you need to do endoscopy (as out-of-hospital) so that the Medical Aid company will settle the medical expenses. It should be noted that if your endoscopy is done in a hospital or a day hospital, you will need to pay a co-payment; If it is done in the doctor's room, there won’t be a co-payment. What should you do if the doctor asks you to request for pre-authorization? You need to ask the doctor for the following information and provide it to the Medical Aid company: • Medical aid membership number • Name the patient • Reasons for hospitalization or surgical items • Date and time of admission • Name and practice number of doctor • Hospital name and practice number • ICD10 codes and procedure codes Maternity Benefit If you have confirmed your pregnancy with your doctor, you can activate the maternity benefits with the Medical Aid company. After that, your medical aid would compensate 8 maternity check-ups up to scheme rate (about R480). Each obstetrician and gynecologists' charges different fees, you will then need to pay the amount exceeding the scheme rate. If your Gap Cover is with Sirago Ultimate option, 4 out of the 8 times, you may claim back the difference paid. Chronic Benefit If you are diagnosed with chronic illness, you can ask your medical aid broker for a chronic illness benefit application form, and ask your doctor to fill it out and send it to the Medical Aid company (or send it to the broker, who will send it to the Medical Aid company). In this way, you can go to the pharmacy for medicine every month, and the Medical Aid company will pay for the medicine. Cancer If you are diagnosed with cancer, you need your oncologist to provide a treatment plan and histology report to the Medical Aid company. Once the oncology benefit is activated, the first R200k of each cycle (12 months) will be paid in full, up to scheme rate. After that, Medical Aid company will pay 80%, and the remaining 20% will be your own expense. (if you have Gap Cover, the 20% co-payment amount can be claimed back) If your Gap Cover is Sirago's Ultimate option, the Gap cover will also compensate you R25k. Day-to-day Medical Expenses - Medical Savings If you are on a Savers option (or higher), you can enjoy day-to-day benefits. Every January, Discovery gives you your full-year savings which you may use throughout the year, if the savings are not used up by the end of the year, it gets rolled over to the next year and you can accumulate it and earn interest. If you are on a Priority, Comprehensive, or Executive plan, you also enjoy the Above Threshold Benefits, given that you have paid up the Self Payment Gap. What can you use Medical Savings for? You can use your Medical Savings for any out-of-hospital medical-related expenses, including but not limited to doctors' consultations, over-the-counter medication, dentists, glasses, certain co-payments (scopes, out-of-hospital CT/MRI scans), etc. Once the savings are used up, you will then need to pay for the medical expenses from your own pocket, until January the following year. Written by: Tammy Hua If you would like to review your Medical Aid option contact Tammy email: service@daberistic.com (tel)11)658-1333 Ext 106 Comments are closed.
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AuthorKevin Yeh Archives
January 2025
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