Accident and emergency

Benefits / Accident and emergency

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    Accident and emergency cover

    Accident and emergency cover includes emergency transportation, stabilisation and treatment cost, as well as the cost of diagnostic scans (like MRI and CT scans), take-home medication, internal and external prosthetics, orthotics and assistive devices, rehabilitation services (like step-down services, wound care, physiotherapy and occupational therapy), subject to both clinical approval and the respective per event limits

    Accident cover:
    Covered at a private hospital for accidents that meet the qualifying criteria

    An accident shall mean a medical emergency that is an external, unexpected event that is not traceable, directly or indirectly, to a member’s state of mental or physical health prior to the event

    Emergency cover:
    Covered at a private hospital for emergency (heart attack or stroke) events that meet the qualifying criteria

    Emergency transportation cover:
    Emergency transportation, stabilisation and treatment cost paid in case of an accident or an emergency (heart attack or stroke) that requires immediate medical treatment

    If the benefit limit is exceeded, and further treatment is required, the
    member will be transported to a state facility for further care and
    treatment

    Base option

    Casualty/emergency room benefit up to R30 000 per event (accidents, heart attacks and strokes)

    In-hospital benefit up to R200 000 per event (accidents)

    In-hospital benefit up to R250 000 per event (heart attacks and strokes)

    Covered at a private institution for accidents and emergencies that fit
    the qualifying criteria

    Standard option

    Casualty/emergency room benefit up to R30 000 per event (accidents, heart attacks and strokes)

    In-hospital benefit up to R1 000 000 per event (accidents)

    In-hospital benefit up to R500 000 per event (heart attacks and strokes)

    Covered at a private institution for accidents and emergencies that fit the qualifying criteria

    An accident can happen at any time and it is important that you know who to call if you are involved in an accident, and you need immediate medical treatment. You have cover for accidents that are external, unexpected events, such as burns, fractures, or the breaking of limbs due to an accident. You will need to call us on 0860 10 29 03 to get authorisation for emergency medical treatment. For emergency ambulance transport, call Netcare 911 on 082 911. Based on your injuries, the ambulance staff will decide on the most suitable hospital to take you to. If you have an authorisation number, the hospital will send the account to us for payment. We will pay up to the benefit option per event limit for casualty treatment, and up to the benefit option per event limit for in-hospital treatment, provided that the treatment is linked to an accident that fits the qualifying criteria. You are not covered for injuries that happen while you are under the influence of alcohol, or for claims for self-inflicted injuries, as well as injuries that you get while breaking the law or participating in civil unrest.

    Your emergency cover also includes a heart attack and stroke benefit. We will pay up to the benefit option per event limit for casualty treatment, and up to the benefit option per event limit for in-hospital treatment, if you should have a heart attack or a stroke. Accident and emergency cover includes emergency transportation, stabilisation, and treatment cost, as well as the cost of diagnostic scans (like MRI and CT scans), take-home medication, internal and external prosthetics, orthotics and assistive devices, rehabilitation services (like step-down services, wound care, physiotherapy, and occupational therapy), subject to both clinical approval and the respective per event limits.

    If you are hospitalised at a private hospital as a result of an accident or emergency heart attack or stroke and the cost of your care exceeds the in-hospital treatment limit, and you need further treatment, you will be transported to a state hospital for further care.

    Please check on your Health4Me membership certificate if you and your family (if they are included on your membership) have accident cover.

    Important definitions:

    An accident shall mean an emergency that is an external, unexpected event that is not traceable, directly or indirectly, to a member’s state of mental or physical health prior to the event. Accidents include but are not limited to falls, fractures, burns, transport-related accidents, the breaking of limbs due to accidental causes, etc. Natural causes are not included in this definition.

    Emergency shall mean the sudden and, at the time, unexpected onset of a medical condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a body organ or part or would place the member’s life in serious jeopardy, and for the purpose of this policy includes, and is limited to accidents, heart attacks, and strokes.

    Emergency medical transportation shall mean the transportation of a member in order that he/she may receive medical or surgical care.

    The casualty/Emergency room is based in an accredited health care facility that is staffed and equipped to provide rapid and varied emergency care for a member who was involved in an accident or has had a heart attack or stroke. The emergency area may use a triage system of screening and classifying clients to determine priority needs for the most efficient use of available personnel and equipment.

    Authorisation shall mean the process (automated or through interaction with the health professional or his/her representative) where a request for intervention or treatment is made by a health professional or his/her representative and where the intervention or treatment is then authorised or rejected for a full or partial benefit.

    Stabilisation shall mean the provision of such medical treatment of the condition as may be necessary to ensure, within reasonable medical probability, no material deterioration of the condition is likely to result from or occur during the transfer of the individual from the facility.

    Accident and emergency cover policy exclusions:

    No Benefit will be payable for any claim if it is in any direct or indirect way caused by, related to, or a result of:

    1. any nuclear reaction or nuclear radiation;

    2. active participation in war, invasion, act of foreign enemy, hostilities or warlike operations (whether war has been declared or not), civil war, military uprising, military or usurped power, martial law, insurrection, rebellion or revolution;

    3. active participation in any mutiny, riot or civil commotion that assumes the proportions of or amounts to a popular uprising;

    4. any act of terrorism or action taken in controlling, preventing, suppressing or in any way relating to any act of terrorism, even if there are other causes or events that contribute to the claim at any stage. In this Policy terrorism means an act, the threat of an act, or any preparation for an act:
    a. which may or may not involve violence or the use of force by any person or group (whether they are acting alone or on behalf of or in connection with any organisation, regime, or any constitutional or practicing government);
    b. that is, or appears to be, intended to intimidate, harm or influence any government, the public, or a section of the public, or to disrupt any segment of the economy; or
    c. from its nature or context appears to be done in connection with political, social, religious, ideological or similar causes or objectives;

    5. excessive use of intoxicating liquor, wilful inhalation of gas or taking of poisons, drugs or narcotics (except under proper medical direction);

    6. any violation of the criminal law by the Member, or any event occurring whilst the Member is in violation of the criminal law;

    7. mining or using explosives unless as part of an occupation for commercial purposes;

    8. any hazardous activity, including but not limited to motorised racing/speed contests, speed trials, boxing (including kick-boxing) or fighting of any kind, except in self-defence;

    9. any risky or dangerous activities which, in the opinion of the Insurer, may expose the Insured Life to a higher than average risk of injury; or

    10. attempted suicide or any self-inflicted injury, whether the Member is sane or insane, and whether by the Member’s own hand or not.