Hospitalisation Procedures

Members are encouraged to always make use of Network Hospitals – failure to do so will result in the member being liable for co-payments.

All planned admissions to hospital require pre-authorisation, which can be obtained by contacting the Society’s hospital pre-authorisation department toll-free at 0800 111 669 at least 72 hours prior to admission. In the event of an emergency, the Society must be notified within 24 hours after the event or the next working day if it falls on a weekend or public holiday.

The Society has a preferred provider arrangement with a number of hospitals throughout South Africa. These hospitals are known as ‘network hospitals’.

- How do hospitalisation benefits work in a network hospital

If you have a procedure done at a network hospital for which you have obtained pre-authorisation from the Society, you will not have to pay any additional charges from the hospital other than in cases where the option exists to have the procedure performed out-of-hospital as noted elsewhere. The Society will settle accounts directly and in full from your service providers, for example surgeon, anesthetist etc. unless it exceeds 200% of SRPL as noted below.

- How do hospitalisation benefits work in a non-network hospital?

Please note that if you have a procedure at a non-network hospital for which you have obtained pre-authorisation from the Society, you may not receive the same level of benefit as you would have if you had used a network hospital and additional co-payments may be incurred.

- How do benefits work in other facilities?

Admissions to day clinics, psychiatric hospitals and step-down facilities is not restricted to network hospitals provided that pre-authorisation from the Society has been obtained. Co-payments may however apply in certain circumstances.

- What about other service providers utilised while hospitalised?

Please remember that when you are in hospital, there are also other costs to consider apart from the actual hospitalisation, e.g. specialists, physiotherapists etc. It is your responsibility to check what the specialists’ charges will be and what portion will be covered by the Society. If the service providers charge in excess of the SRPL tariffs, the Society will apply the Scheme Rate to these claims only if the hospitalisation has been pre-authorised at a network hospital. Any charges higher than the Scheme Rate will be for the members account notwithstanding that it has been pre-authorised.

- How do benefits for Day Procedures work?

A same day admission, if authorised as such, will qualify for benefits if the admission and discharge occur on the same day without any overnight stay. Should an overnight stay subsequently be required, the difference will be for the member‘s account.

If admitted to a non-network hospital, the entire account will change to the SPRL rate and the member will be liable for any difference in costs from admission until the time of discharge, if there is an overnight stay.

Members are encouraged to ensure that if they are admitted for a day procedure that their doctor performs the procedure early enough in the day to ensure that an overnight stay is not required for recovery from anesthetic.

- How can I minimise costs not covered by the Society should I need to have an operation?

Find out from your referring doctor or specialist what service providers will be involved in your case, for example:

o the surgeon(s)

o the anaesthetist

o any doctors or specialists assisting the surgeon

o follow-up treatments in hospital, such as physiotherapy, pathology tests, x-rays, etc.

Ask the doctors/service providers what they will charge in comparison with the SRPL tariffs. You can contact the Society on 053 807 3400 for information on SRPL tariffs. Negotiate with all your service providers to charge the SRPL tariff if they quote a higher rate. If you are not successful, consider using an alternative specialist as you will be liable for the additional costs.

- What if the procedure can be conducted in the doctor’s consultation rooms?

Certain medical procedures can be performed in a doctor’s consultation rooms and it is not necessary for members to endure the inconvenience of being admitted to hospital. Members would need to request authorisation for indicated procedures and the Society would then provide benefit up to Scheme Rate, thus reducing the possibility of member co-payments. No authorisation is required for minor (non-booked) in-rooms procedures, but please contact the Society’s hospital pre–authorisation department if you require clarification.

Co-payments of R1,500 apply to colonoscopies, arthroscopies, laparoscopies, circumcisions and male sterilisations that are performed in-hospital as it is possible and general practice for these procedures to be performed in the doctor’s consultation rooms. When requesting authorisation for a planned procedure, the Society will indicate to the member whether a co-payment is payable or not by providing written confirmation of the authorisation. When two or more of the above procedures are performed simultaneously in hospital, only one co-payment will be levied.

- Can I settle my co-payments by paying service providers directly?

If you do not want the Society to pay the service provider’s claimed amount on your behalf and collect co-payments from your salary or pension, please notify the Society in writing. In such cases the Society will only settle its liability with the service provider according to the Rules, and the member will be required to settle the remaining portion of the account directly with the service provider.

- In which countries will I be covered for benefits in terms of the Society’s Rules?

Coverage for benefits as outlined in the benefit table above in general only applies within the Republic of South Africa, provided that:

- benefits will be extended to Members and their Dependants in Botswana or Namibia during the employment of such Members by the Employer or an Associated Employer in either of those countries; and

- Members or Dependants who are enjoying benefits in respect of relevant health services rendered in Botswana or Namibia will, on becoming retired members, continue to enjoy such benefits for as long as they remain permanent residents of the country in which they were receiving benefits at the time when they became retirees as provided for in rule 6.2, or became eligible for Membership as provided for in rule 6.3 (as the case may be).

Please note that ER24 coverage will generally only apply to emergencies in the RSA and for members resident Botswana and Namibia as outlined above. If you are a RSA citizen, resident in the RSA who is travelling on holiday to Botswana or Namibia or, for that matter, to any other country in the world, you will not be covered by ER24 or by the Society and you are therefore advised to arrange appropriate travel insurance in good time before you depart.