Overview

According to the Medical Schemes Act, emergency care and treatment are Prescribed Minimum Benefits (PMB). All medical schemes have to pay for these benefits in full. When you use the services of a Designated Service Provider, all claims, including Prescribed Minimum Benefits, are paid in full. This means you will not have to make out-of-pocket payments at these providers.

These Designated Service Providers are specific providers of healthcare services, for example General Practitioners and Specialists, who have agreed to provide services according to certain agreed rules. The Scheme pays these providers directly.

In certain instances you must use the services of the designated service providers. If you do not use these services you may have to pay deductibles or make co-payments

An emergency medical condition is defined as:

The sudden, and at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment of bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy.

A stroke, cardiac arrest, fractured hip or even an emergency appendicitis or serious eye injury would be regarded as an emergency, despite the fact that the patient may be fully conscious. It is impossible to give a definitive list of all possible conditions that might constitute an emergency medical condition. This determination can only be made by the attending doctor, who must submit the account under the correct emergency codes. Please note that not all emergency visits are Prescribed Medicine Benefits.