Keep the number for an emergency

Private ambulance service Netcare 911 says it will respond to any call when there is a genuine medical emergency, regardless of which the patient's financial status or to which scheme the patient belongs.But a large medical scheme says if its members do not use the emergency service it has appointed, they could face a co-payment, unless they can demonstrate that they were incapable of calling another emergency.

Netcare is one of two main private emergency service providers in South Africa - the other is ER24. Many medical schemes have contracts with one of these two providers.

Dr Ryan Noach, the chief executive of Netcare 911, says if a member of scheme with an arrangement with Netcare, calls the service from one of the telephone numbers provided to the scheme, Netcare will immediately have access to that members' details including your address and your medical records, saving precious time in an emergency.

Emergency services are prescribed minimum benefits (PMBs) that all schemes must provide by law. But schemes can appoint certain designated service providers (DSPs) that members must use to enjoy cover for those PMBs.

Oxygen medical scheme has appointed ER24 as its DSP for emergency services. James van Vught, the principal officer of Oxygen, says this means that in an emergency, Oxygen members are expected to call ER24, unless they are incapable of doing so - for example, if you are unconscious after a motor vehicle accident.

Van Vught says that if you call out a different emergency service, you could be faced with a co-payment.

The regulations governing medical schemes stipulate that when members "involuntarily" make use of a provider other than a scheme's DSP, the scheme must pay. Exactly what is meant by involuntary has yet to be tested in court.

Noach says that in practice schemes - like Bonitas, contract with Netcare to provide emergency services for a set fee per member. The costs of a member calling out a Netcare ambulance are covered. But if a Bonitas member calls out an ambulance from, for example ER24, there are agreed service level terms between ER24 and Netcare 911, and Netcare will consider the claim in light of how medically justifiable it was and the medical care rendered, and pay ER24 what it believes is the reasonable cost.

But a co-payment could arise if you call an ambulance when it was not justified. To avoid a co-payment, Van Vught says, Oxygen has informed its members that they must call ER24.

Jacky Mathekga, the principal officer of Discovery Health Medical Scheme, says Discovery has engaged ISOS to assist with ambulance services to its members. ISOS have access to all private and public ambulance services.

They manage the emergency incident and decide on the closest and most appropriate service provider. They ensure that an ambulance is dispatched, regardless of whether it is Netcare 911, ER24 or municipal service and the scheme will pay for the services provided with no co-payment from members.

In cases where you need an ambulance but there is no emergency, for example, if you're being transferred from one hospital to another, you must use the service your scheme has appointed and you need authorisation.

Personal Finance - 25/06/05

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