Why do Medical Aids sometimes refuse casualty treatment?

Will my medical aid pay for hospital casualty visits?

Have you suffered an after-hours hospital casualty visit that your medical aid never covered?
An emergency visit because it was the weekend,and your GP was unavailable.
Or your child dislocated a shoulder at school rugby and needed immediate care.

You received attention at your local hospital casualty (as you would expect), but your medical aid declined the claim, leaving you angry and believing your scheme is useless.

This may be the reason your claim was refused …

An Emergency Centre is not part of a private hospital.
An Emergency room, located in a private hospital, is not owned by that hospital. It is owned by the doctors and specialists who run it.
They rent the space from that hospital and are not part of that hospital at all.

Treatment

Patients are treated by the doctors and other healthcare providers employed by the facility. Treatment can vary from a consultation (with or without a prescription), diagnostic tests like blood tests, X-rays, ECG, drip, medication and so on. Stitches, splinting or plaster cast of a limb etc.

If the treatment is not related to a defined medical emergency or a PMB (Prescribed Minimum Benefit) condition and the patient is not admitted to hospital, the services rendered are deemed to be out of hospital.
As such, they will be paid from your day-to-day benefits.
They are not payable from a risk or in hospital benefit.

If the patient is treated in casualty and then immediately admitted into hospital either a medical aid authorisation (or a deposit if not a medical aid member) will need to be confirmed.
Thereafter, the normal hospitalisation treatment is funded in terms of the medical aid plan.

Your medical aid is not in the wrong if claims are not paid. They are applying the rules of the scheme.

Here is a plan that pays trauma related casualty where you are treated at an emergency room and return home.

a medical aid plan for everyone As a medical aid member, you need to understand what your benefits and limits are. Please do this before you land up with unpaid claims, especially if you only have an in-hospital plan, as there is no day-to-day funding and you are responsible for the cost.

Remember that comprehensive plans with day-to-day savings do cost more than an in-hospital only plan.

If you accept the small risk of self-paying out of hospital costs, you can save on the overall cost of your medical aid by joining only a hospital plan.

Here is an excellent plan that meets both the need for a hospital only plan (and lower premium) and that offers an out of hospital savings fund should you require it.

You only pay for the savings when you spend them – not like other comprehensive plans that require you to pay for the savings whether you spend them or not!

Please look at this highly recommended, innovative medical aid!

Remember that comprehensive plans – those with day-to-day savings -cost more than hospital only benefit plans.
You get what you pay for, when it comes to medical aid.

Get professional advice on what medical aid may suit you best.

Private healthcare providers can charge up to 500% of medical scheme rates.
Medical aids add procedure co-payments as well.
These are significant concerns for medical aid members.

Protect yourself against these potential threats, by joining Cura's GAP or top-up insurance plan.
OR Zest GAP or top-up insurance plan.

This separate insurance will cover most in-hospital claim shortfalls and any co-payments. It is a vital safety net, ensuring you have adequate benefits for medical treatments without bearing the full burden of unexpected costs.

Protect yourself from soaring medical expenses by bridging the gap between medical scheme rates and the charges imposed by private providers.

Specialised Dental treatments can be extremely expensive!
The costs of braces, root canal, implants and so on, can run into thousands of rand. Most treatments are done out of hospital, so are funded from your savings. That can result in less money available for other medical needs and family limits being used on one member only!

Dental treatment is something we all need and it is vital you consider the Best Dental Insurance Plan OR Most Affordable Dental Planin South Africa.

No Medical Aid or have a Hospital Plan only? This plan will help you meet the high costs of both normal and specialised dentistry!

Talk to me .... I am here to help you - at no charge!
Send me your questions and concerns. I'll answer them for you.

083 655 2164

You must consult the schemes/company product brochures and rules for comprehensive benefit descriptions.

We will offer you the best help at no cost!

Medical aid pays healthcare costs.
What if a disability stops your income?

YOUR TRUSTED, QUALIFIED ADVISOR:
Peter Pyburn - Authorised Financial Services Provider, fully licensed to render financial services since 1991. Death and Disability Planning; Retirement Planning; Investment Planning; Healthcare and Estate Planning.

Council of Medical Schemes

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January 18, 2025