Emergency and ambulance cover explained

The regulations define an emergency medical condition as the sudden and, at the time, unexpected onset of a health condition that needs immediate medical or surgical treatment, where failing to treat it would seriously impair bodily functions, seriously damage an organ or part, or put the person's life in serious jeopardy.

For that kind of condition:

• The scheme must pay the diagnosis, treatment and care costs in full, without a co-payment or deductible, on every plan.
• You may go to the nearest healthcare facility, even if it is not a DSP.
• A scheme may not prohibit a provider from starting appropriate treatment before receiving authorisation.
• Exclusions do not apply to PMBs.

Whether a condition meets the definition is a medical judgement, not a matter of how urgent it felt. If the scheme disputes it later, challenge that in writing. Read the full prescribed minimum benefits guide.

Only call the number your scheme publishes for emergency transport. The table lists the ones we could verify.

Scheme numbers can change, so confirm on your member card or app. Our medical aid contact numbers page lists each scheme's other lines.

Some schemes do not publish a clear ambulance line, so check your member card.

• Cape Medical Plan lists 079 298 5548 as an emergency contact but says it is not a number to call an ambulance. Emergency admissions must be authorised within 72 hours.
• Sizwe Hosmed lists 082 911 as "Medical Emergencies and Ambulance" but does not name the provider on its contact page.
• Thebemed publishes a Netcare 911 emergency number that differs from the 082 911 used by other schemes. Verify it with the scheme before you rely on it.
• Suremed lists ER24 on 084 124 on its contact page and benefit schedules, but another page on its site gives a different number. Confirm with the scheme.

If yours is not listed, or the card is unclear, call the scheme's main number in daylight hours and ask, and use the national emergency number in an actual emergency.

1. Call your scheme's emergency number from the table, or your app's emergency button. Discovery's app Emergency assist calls are answered by a dedicated Netcare 911 team who dispatch an ambulance to your location. Remedi's app offers Emergency Assist without logging in.
2. Go to the nearest appropriate facility. Do not delay treatment to phone for authorisation.
3. Give the hospital your membership number and dependant code.
4. Notify the scheme. The rules differ. Genesis asks the hospital or member to notify it on the first working day after an emergency admission, and Cape Medical Plan requires authorisation within 72 hours. LA Health says any emergency transport must be authorised through Discovery 911.
5. Keep paperwork: the hospital account, ambulance invoice and authorisation number.

If someone else is with the patient, hand them your membership number and ask them to make the call while you stay with the patient.

Once the patient is stable, the scheme may ask to move them to a network or designated hospital to continue care under normal benefits. Ask what the scheme will pay for the rest of the stay before agreeing, and get any transfer decision in writing.

Check the bill against the rules:

• A genuine emergency PMB must be paid in full without a co-payment or deductible.
• If you were treated at a non-DSP because you had no choice, no co-payment is payable. The regulations treat use of a non-DSP as involuntary when immediate treatment was needed where a DSP could not be reached, or when no DSP is within reasonable proximity.
• The scheme may use pre-authorisation, protocols and formularies for PMBs, but it may not stop the provider starting emergency treatment.

If a co-payment or refusal seems wrong, ask the scheme in writing for the reason, then use its internal dispute process. If that fails, complain to the CMS. See designated service providers, pre-authorisation and the complaint letter template.

Health insurance products are not medical schemes, are exempt from the Medical Schemes Act, and do not have to cover PMBs. Complaints about them go to the National Financial Ombud, not the CMS. Their emergency benefits are different.

• Dis-Chem Accident Cover pays for Netcare 911 road transport and stabilisation, emergency department visits and in-patient hospitalisation for accidental harm only, up to R380,000 per event and R1.5m per insured person per year. It does not pay for illness or planned admissions.
• Oneplan's Core Plan includes repatriation and ambulance assistance, and its hospital authorisation, admission and emergency line is 010 0010 141, available 24 hours.
• Affinity Health points members to the iER (Integrated Emergency Response) app, a third-party emergency app, and a 24-hour pre-authorisation service. It publishes no emergency phone number on the pages we checked.
• Kaelo lists Netcare 911 on 082 911 for transport after hours.

See medical aid versus health insurance before treating any of these as a replacement for a scheme.