What to do before you go to hospital

Before you go to hospital for any planned procedure, you must:

• See your doctor
• Call us on 0860 100 693 to confirm your hospital admission at least 48 hours before you go in. If you do not confirm your admission, we will only pay 70% of the costs that we would normally cover.

Cover is subject to our Scheme rules

We pay medically appropriate claims. Your cover is subject to our Scheme rules, funding guidelines and clinical rules. There are some expenses that you may incur while you are in hospital that your benefit does not cover, for example private ward costs. Certain procedures, medicines or new technologies need separate confirmation while you are in hospital. Please call us on 0860 100 693 to confirm.

Cover for Prescribed Minimum Benefits (PMBs)

For Prescribed Minimum Benefits, we pay hospital admissions for approximately 271 defined conditions in full, if you have treatment at one of our Designated Service Providers (our choice of healthcare professionals). If you do not use our Designated Service Provider you may have to pay the difference between what the healthcare professionals charges and what the Scheme pays. Click here for a list of our Designated Service Providers

Cover for medical emergencies

What is a medical emergency?

A medical emergency is the sudden, unexpected onset of a health condition that needs immediate medical or surgical treatment. If this treatment is not provided the person’s life would be at risk or result in serious impairment or dysfunction of an organ or body part.

Cover for medical emergencies in South Africa

We cover you in hospital for emergency and planned hospital admissions. In an emergency, go straight to hospital but call us or get someone to call us within 12 hours. We will cover your emergency admission in full as a Prescribed Minimum Benefit in whatever hospital you are admitted

We cover HIV prophylactics

If you need HIV prophylactics to prevent HIV infection from mother-to-child transmission, occupational and traumatic exposure to HIV or sexual assault, call us on 0860 100 417.

How we cover your healthcare professionals

Your healthcare professionals’ accounts are separate from the hospital account. Healthcare professionals accounts may include specialist accounts and other related accounts, for example accounts from a surgeon, anaesthetist, pathologist or radiologist. Healthcare professionals are free to set their own rates. If they charge the Scheme Rate, we will pay them directly. If they charge more than the Scheme Rate, we will pay you. You will then need to make sure you pay your healthcare professional the full amount.

If your healthcare provider is a provider participating in the Discovery Health Network they will be covered in full. Click here to access the MaPS tool to search for the healthcare professionals who participate in the Discovery Payment Arrangements (DPA's).

Treatment in hospital that we cover from your day-to-day benefits

We cover the following treatment you get in hospital from your Medical Savings Account:

• Casualty and emergency treatment, if you are not admitted
• Medicine to take home
• Certain external medical items, once your Insured Procedures Benefit limit is depleted

The Africa Claims Benefit

Anglovaal members have access to the Africa Claims Benefit. The Africa Claims Benefit will fund claims outside of South Africa at the Scheme Rate if it is for a procedure or claim that would normally be covered under the member's benefits. The member will have to pay for medical expenses upfront and submit the claims to the Scheme. These claims are paid at the Scheme's discretion.

Non-emergency or elective treatment in hospital

The Africa Claims Benefit covers non-emergency or elective treatment as long as the same treatment is readily available in South Africa and it would normally be covered in South Africa in terms of the member’s benefits and the Scheme’s rules. The benefit covers non-emergency or elective treatment in hospital at the South African benchmark equivalent, as a global fee (a single amount that we calculate based on an average cost for all related, appropriate healthcare services related to a specific event or episode). The member will have to pay for medical expenses upfront and submit the claims to the Scheme. These claims are paid at the Scheme's discretion.

Out-of-hospital non-emergency or elective treatment

You will need to pay for these medical expenses upfront and send the claims to the Scheme. If approved, we only pay these claims into a South African bank account at the South African benchmark equivalent, as a global fee (a single amount that we calculate based on an average cost for all related, appropriate healthcare services related to a specific event or episode). These claims are paid at the Scheme's discretion.

If you are admitted to hospital from casualty, we will cover the costs of the casualty visit from your Hospital Benefit, as long as we confirm your admission. If you go to a casualty or emergency room and you are not admitted to hospital, we will pay the costs from your day-to-day benefits (Medical Savings Account). Some casualties charge a facility fee, which we do not cover.

+ Information on how we cover childbirth

We cover childbirth from your Hospital Benefit, including home births done by midwives with valid practice numbers and who are appropriately registered with the Board of Healthcare Funders. You must authorise the childbirth admission to hospital or home birth with us beforehand. Remember to register your baby with us as soon as possible so we can cover the baby.