Africa Evacuation Benefit

Transcription

1 Africa Evacuation Benefit 2016

2 You can read this document to find out everything about Discovery Health Medical Scheme s ( DHMS/Scheme ) Africa Evacuation Benefit ( Africa Benefit ) for It will give you more detail about the following: Who we cover under the Africa Benefit Which African countries we cover How we cover medical emergency evacuations from a defined list of sub-saharan countries to South Africa What happens in a medical emergency Cover for non-emergencies What we do not cover under the Africa Benefit How to claim from the Africa Benefit Contact details This benefit covers members working and/or living in certain African countries An increasing number of employers are sending employees on assignments to other African countries. As a result, the demand for medical emergency evacuation benefits is growing. The Africa Benefit fulfils this need. The Africa Benefit is available on the Executive, Classic, Smart, Essential and Coastal plans. This benefit is not available on KeyCare plans. You don t have to register to gain access to the benefit. Included in the Africa Benefit is cover for you and your dependants: for the usual, reasonable costs of medical emergency treatment, which must be from a qualified healthcare professional emergency transport and evacuation to an appropriate facility in South Africa to enable you or your dependant to stabilise for the return to South Africa. If you or your dependant are capable of being repatriated and elect not to return to South Africa, you will be responsible for all expenses incurred after the decision to repatriate. When travelling to a country covered under the Africa Benefit, certain healthcare services in the first 90 days after your departure from South Africa will be covered according to the International Travel Benefit. For more information about the International Travel Benefit, please visit read the International Travel Benefit summary or the Scheme Rules. Medical emergency evacuations from a defined list of sub-saharan countries to South Africa The Africa Benefit covers medical emergency evacuations from the African country where you or your dependants live, to South Africa, if International SOS gives the go-ahead. The benefit applies to a defined list of sub-saharan countries in Africa, as well as the islands of Madagascar, Mauritius, Seychelles, Réunion and the Comoros. PAGE 2 OF 6

3 African countries that are covered: Angola Equatorial Guinea Republic of Congo Benin Gabon Réunion Botswana Ghana Rwanda Burundi Kenya Seychelles Cameroon Lesotho Somalia Central African Republic Madagascar Swaziland Comoros Malawi Tanzania Democratic Republic of the Congo (DRC) Mauritius Togo Djibouti Mozambique Uganda Eritrea Namibia Zambia Ethiopia Nigeria Zimbabwe What to do if you need medical emergency evacuation If you need a medical emergency evacuation, you have to call International SOS. Once they have given the go-ahead for the evacuation after verification, they will also arrange it. You or your dependant will be evacuated to South Africa, where you will receive medical treatment. Healthcare services given in South Africa are covered according to your chosen health plan and the Scheme rules. The minimum requirements for evacuation are as follows: o There must be an airport or runway in good enough condition for aircraft accessibility o There should be no security risks in accessing the destination at the time of evacuation o There should be no Civil Aviation Authority restrictions in respect of airspace Medical claims incurred in the African country where you live, immediately before to and relating to the emergency evacuation, are also covered by the Scheme. Payment will be according what would have been paid locally in South Africa, based on past claims experience, according to the your chosen health plan type. We will only cover your return transport to the African country where you live, if you need a medical escort. The Africa Benefit only covers evacuations due to medical emergencies. For elective or planned treatments, you can still contact International SOS for help and you will be responsible for paying all costs related to the evacuation. Out of hospital, non-emergency or elective treatment The Africa Benefit covers non-emergency or elective treatment if the following conditions are met: The treatment must be readily available in South Africa The treatment must be covered in terms of the Scheme rules. PAGE 3 OF 6

4 If the treatment meets these criteria, you will need to pay for these medical expenses upfront. You can then submit the claims to us. We will reimburse claims into your South African bank account. We will cover healthcare services related to the treatment, according to the South African benchmark equivalent. This is known as a global fee. A global fee is a single amount that we calculate based on the average claims experience on your specific plan. Clinical protocols apply. This means that we only pay medically appropriate claims. Your cover is subject to the rules of the Scheme, funding guidelines and clinical policies. This cover only applies to healthcare services received in the covered African countries. Other services that are covered at a South African global fee The rules for out-of-hospital, non-emergency, or elective treatment also apply if you access any of the following healthcare services while in one of the covered African countries: pregnancy or childbirth if medical complications or emergencies arise after the 24th week of pregnancy. If the baby is born outside South Africa, he or she will not be covered by the Scheme until you return to South Africa and register them on the Scheme situations where you or your dependants are aware of a reason which could give rise to any claim situations where you or your depedants are travelling contrary to medical advice, or with the intention of obtaining medical treatment, or where a terminal prognosis has been given renal dialysis or chemotherapy as well as healthcare services relating thereto emergency treatment for conditions and complications thereof for which treatment was received at any time during the 30-day period immediately before the date of departure from South Africa healthcare services in respect of cancer diagnosed and/or treated within the 12-month period immediately before the date of departure from South Africa healthcare services in respect of organ failure diagnosed and/or treated within the 12-month period immediately before the date of departure from South Africa. Prescribed Minimum Benefits don t apply beyond South Africa s borders. How to arrange direct payment for in-hospital, non-emergency/elective treatment You need to contact International SOS for approval before going to hospital for the procedure and give them the following information: Your membership number Date of planned procedure Name and practice number of the hospital Name of treatment or procedure. International SOS will approve payment to the hospital at the South African benchmark equivalent, based on: The claims experience on your plan type The Scheme s clinical policies The rules of the Scheme. PAGE 4 OF 6

5 This cover only applies to healthcare services received in the African countries listed. Any amount over the approved payment will not be paid. What the Africa Benefit does not cover You are not covered for any of the following while living in one of the covered African countries: Healthcare services related to a waiting period, if applicable Healthcare services related to a pre-existing condition where a member or dependant is aware of a reason which could give rise to a claim Healthcare services related to one of the Scheme s general exclusions. For a list of these exclusions, please refer to your Health Plan booklet, or visit Any claims incurred if you are on a KeyCare Plan. Procedure for submitting claims You can send claims to Discovery Health by post to PO Box , Sandton 2146 or fax to Alternatively, claims may be scanned and ed to claims@discovery.co.za Please send us the following information: A detailed, original account from the healthcare provider The International Travel Benefit (ITB) claim form, completed in full and including proof of payment for all attached claims. Please send claims to us within four months of the date of service and remember to keep copies for your records. Please mark your claims as International claim and put your membership number on each page. Contact numbers In case of an emergency, call International SOS on If you need help with contacting International SOS in an emergency, you may also contact the international operator of the country you are visiting and ask to be connected to International SOS on reverse call charges. If you have a query about the payment of your Africa Benefit claims, you can call Discovery Health on Complaints process You may lodge a complaint or query with Discovery Health Medical Scheme by completing an online complaints form on or address a complaint in writing directly to the Principal Officer. Should your complaint remain unresolved, you may lodge a formal dispute by following Discovery Health Medical Scheme s internal disputes process on the Discovery website. Members who wish to approach PAGE 5 OF 6

6 the Council for Medical Schemes for assistance, may do so in writing to: Council for Medical Schemes Complaints Unit, Block A, Eco Glades 2 Office Park, 420 Witch-Hazel Avenue, Eco Park, Centurion, 0157 or complaints@medicalschemes.com. Customer Care Centre: / website PAGE 6 OF 6