When is a medical emergency an emergency?

You think there’s something seriously wrong with you, because you are having chest pains, and you go off to the trauma unit on a Sunday afternoon.

But many people have had an unpleasant surprise when their medical scheme or hospital plan does not want to pay for this, and they get landed with the bill, which could be substantial.

When will your medical scheme or hospital plan pay, and when will you be footing the bill?

Here are 10 questions and answers that should help to clear up this issue.

Is there an internationally accepted definition of an emergency?

No, there isn’t. There are so many factors that have to be taken into account, which no one has yet come up with a universally accepted definition of what constitutes an emergency.

Does the SA Constitution say anything about emergency treatment?

Yes, it does. Section 27(3) of the Constitution states that “no one may be refused emergency medical treatment”. This is clearly in reaction to ghastly stories from the past, where badly injured patients were sent away from hospitals because of their race – often with dire consequences. But it is a provision that is not without its complexities and ethical problems, and the law states that even private healthcare establishments have to render basic medical treatment “without fear, favour or undue financial demand”.

This raises three immediate issues: what is ‘due financial demand’, when can a patient who is unable to pay be transferred to a state establishment, and if they cannot, who will foot the bill? So there are clearly some issues that still need to be resolved.

What does the Medical Schemes Act of 1998 say is an emergency?

The Act defines an emergency as follows: “An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.”

The words and phrases that are important here are ‘sudden’ (not something you’ve had for three weeks), ‘unexpected’ (if you have just had a shoulder replacement, you expect to be in a certain amount of pain), ‘weakened bodily functions’ (in other words a long-term consequence) and ‘serious and lasting damage to the organs’ (this would include something such as permanently reduced lung function, damage to the heart, and so forth).

In other words, there has to be a chance of serious long-term consequences (even death) if treatment is not obtained immediately. You would not wait until Monday morning to seek treatment if you have sustained the kind of injury that is causing blood loss on a Sunday afternoon. But you might if you think you might have cracked a toe – and in this case your first stop would be the GP, not the trauma unit.

Who pays for ambulance services?

Most schemes will pay for ambulance services in an emergency and for inter-hospital transfers to designated service provider (DSP) facilities.

Schemes will not pay for a transfer that is not necessary just because you want to be closer to home, and they will also not pay if the transfer is purely your personal choice (such as when you want to be closer to a particular doctor), or when it is not clinically appropriate. If a regional hospital is unable to treat your particular condition, because it lacks the facilities, you will be transferred to a DSP in one of the main centres.

If you have been excluded on joining a new scheme from treatment for a certain condition (for a maximum of 12 months) because of your medical history, the scheme will not fund your transfer to hospital or your emergency treatment if it is for that particular excluded condition.

State ambulances can be free as can be state hospitals – but if you are employed, you could receive a bill from a state hospital, but the costs are usually a fraction of what the private hospitals would have charged. In an emergency, though, you might not want to wait the possible extra time for a state ambulance.

If I am in a car accident, I obviously won’t have time to notify the hospital and get an admission number. What happens then?

The staff at the hospital will contact your scheme and notify them of your accident and your subsequent admission to the emergency unit/hospital.

What if I don’t use a Designated Service Provider (DSP)?

If your condition is life-threatening, the law requires that you initially be treated at the nearest appropriate facility, whether it is a DSP, or not. If you have been stabilised, and it is safe to move you, schemes will fund this. An example of this is if you are involved in a car accident, and your nearest DSP facility is 500km away, you will initially be treated at the nearest non-DSP facility.

Many scheme require their members to use DSPs, or risk having to make co-payments. If your condition is not an emergency, and you choose to use a non-DSP, much of the bill could be for your own pocket.

Many emergency units at private hospitals are run by private doctors, so you will be billed by the practice for the treatment and not the hospital itself.

When does my scheme or hospital plan not have to pay?

If you are not admitted to hospital from the emergency room, because things turned out to be less serious than you thought, and if your condition is not one of the PMBs (Prescribed Minimum Benefits – see attached list of conditions from the Medical Schemes Council).

If, however, it is found that your condition did not require emergency treatment, and also was not a PMB, you could be landed with the bill yourself.

Who pays for any diagnostic tests?

Once again, if your condition turns out to be a PMB, and you are admitted to hospital, your scheme will pay. However, if you are not admitted, the tests could be for your own account, or might be paid from your day-to-day benefits if you have a full medical scheme, and not just a hospital plan. If you are admitted to hospital, the costs will usually be paid from your risk benefits and not from your day-to-day benefits.

Are these rules hard-and-fast?

No. Each emergency that is not automatically covered by your scheme (ambulance transport included) is evaluated by the scheme and the funding decision, whether for emergency admission, hospital admission, or tests, is based on the merits of each case.

Are there major differences between the different options on hospital plans and medical schemes?

Yes, there can be. It is essential that you get to know the details of the benefit schedule of the particular option you have chosen. All schemes will have to pay (except for the stated 12-month exclusion) for any emergency for which you are admitted, if the condition is a PMB. But when it comes to the rest, such as the footing of the bill for MRI scans, there can be huge differences between the different schemes, especially if you are not admitted to the hospital for treatment.

(Sources: Council for Medical Schemes; Genesis Medical Scheme; The Medical Schemes Act 1998; Constitution of the Republic of SA)

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