Benefits & Cover
Overview
Benefits for medical costs incurred in South Africa (within the SAU territory)
If required, accounts must be paid in full by the member and submitted together with receipts to SEDMED for processing.
It remains the member's personal responsibility to ensure that claims together with the relevant invoices and receipts are in the possession of SEDMED by not later than the end of the 4th (fourth) month following the date on which the service was rendered. If claims are not submitted to SEDMED within the 4 month period, SEDMED,after considering the circumstances surrounding the late submission, can elect not to honour payment of the claim.Benefits for medical costs incurred outside South Africa (beyond the SAU territory)
SEDMED will cover relevant and specified medical costs incurred in respect of a beneficiary whilst such beneficiary is beyond the borders of the SAU territory will be limited as follows:
- SEDMED will only consider the payment of benefits relating to treatment or medication in respect of pre-existing conditions and those conditions which are excluded by the international medical & travel insurance policy.
- SEDMED cover will not exceed a period of 90 days per any given year, including departure and arrival dates. A year is defined as the period from 1 January to 31 December.
- SEDMED cover shall be limited to the cost of comparable medical care within the SAU territory and in accordance with the rules of SEDMED.
- Adequate international medical & travel insurance must be taken out for the beneficiary travelling overseas in accordance with SAU Policy Y 30 15 45.
- SEDMED membership contributions must be kept up to date during the entire period of absence from the SAU territory, at all times and without interruption and it is the responsibility of the member to provide clear instructions to his/her pay point to continue payment of the required contributions to SEDMED.
- SEDMED membership will terminate immediately if payment of membership contributions is interrupted or terminated for whatever reason and all benefits will be forfeited.
- Payment of medical benefits for which SEDMED may possibly be liable will be limited to the cost structure of comparable medical treatment and medication within the SAU territory in accordance with the rules of SEDMED.
- Once the beneficiary has exceeded the limit of 90 days referred to above, SEDMED will have no further obligation with regard to the payment of any medical aid benefits in respect of such a beneficiary, including chronic conditions. In order to be able to claim any further benefits the beneficiary must first return to the SAU territory for the required treatment or medication subject to the SEDMED membership contributions having been kept up to date as required in 2. above.
- SEDMED reserves the right to ensure that these provisions are not abused.
- Beneficiaries should purchase adequate chronic (CDL and non-CDL) medication before their departure. In order to claim the said medicine in advance, SEDMED must be contacted by the member and requested to authorise Mediscor to approve the provision of medicine in advance. Failure to comply with this process will result in refusal by the pharmacy to provide medicine in advance.
Out-of-Hospital Benefits
- Out of hospital claims are paid @ 75% according to the SEDMED rates.
- The Overall Annual Limits are as follows:
- Member only (M) R8 000.00
- Member + 1 dependant (M+1) R14 000.00
- Member + 2 or more dependants (M+ 2) R20 000.00
- In order to preserve SEDMED funds, patients should always insist on being charged according to the medical aid rates (usually referred to as“contracted in rates”).
- Members are encouraged to negotiate discounted rates as far as possible and to make use of Designated and Preferred Service Providers (Pharmacies: Dis-Chem and Clicks).
- Members are encouraged to use generic equivalents of patented medicine wherever possible.
- The costs of all consultations, procedures or treatment by general practitioners, physicians, specialists, physiotherapists, optometrists etc (this list is not conclusive) in their consulting rooms, including out-patient treatment, is seen as out of hospital treatment and covered as such.
- The cost of prescribed medicines (also prescribed by pharmacists) not qualifying as chronic medication is covered under the out of hospital benefit.
- The cost of ordinary dentistry is covered under the out of hospital benefit.
Here follows a list of specific out of hospital benefits to take note of:
Prescribed Minimum Benefits (PMB)
(Benefits DO NOT accumulate towards annual benefit limit)
SEDMED is required to provide unlimited cover for Prescribed Minimum Benefits as defined in the Regulations to the Medical Schemes Act. This however does not mean that SEDMED cannot adopt and apply treatment protocols and formularies in regards to PMB treatment. A complete list of the current PMBs can be downloaded from the website of the Council for Medical Schemes at www.medicalschemes.com
Hospital-related Events and Accounts
Pre-authorisation
PPS Health Administrators manages the hospitalisation treatment benefit of the Fund. Therefore all authorisation requests for hospital related events or benefits that require pre-authorisation must be obtained from PPSHA going forward.
The pre-authorisation call center number is: 012 679 4107Mediclinic, Life Healthcare, Day Hospital Association (DHASA) and specific National Health Network (NHN) facilities are Designated Service Providers (DSP) for SEDMED.
As of 1 January 2024, the above hospitals have been appointed as DSPs for Sedmed. Members are required to make use of these DSP for any hospital admissions except where such a DSP is not readily available. Where a member voluntary makes use of a non-DSP facility the member will have a co-payment on the hospital account. During the pre-authorisation process, PPSHA will guide the member to a DSP facility. Below you will find a DSP search function which will enable members to search for a DSP facility within their area:Procedures, Benefits and Conditions
- Pre-authorisation must first be obtained from PPSHA at least 24 hours prior to treatment or admission.
- In the event of an emergency, post-authorisation must be obtained on the first working day following emergency admission or treatment. (See definition of Emergency).
- The facility and all other service providers must be advised of the authorisation number allocated by PPSHA and requested to quote this number on all accounts and correspondence.
- Payment of Hospital Related Benefits (HRBs) is restricted to Hospital Related Events (HREs).(See definition).
- In order to preserve SEDMED funds patients should always insist on being charged according to SEDMED rates (usually referred to as “contracted in rates”). Many service providers, including specialists, are willing to do so, if asked. SEDMED may refuse to settle an account in full and pay only according to SEDMED rates. In such cases members will remain responsible for the payment of the balance. A member will not be able to claim benefits in relation to any such balance.
- The maximum Hospital Related Benefits (HRBs) payable are R500 000 per family per annum except in the event of a Prescribed Minimum Benefit condition (See definition).
- Provided pre-authorisation has been obtained (or post-authorisation in the event of an emergency) and SEDMED had been able to make suitable arrangements for the payment of hospital accommodation and all related costs, SEDMED will pay all related invoices at Scheme rates, in full and upon receipt. See comments on INVOICES/ACCOUNTS below.
- Any accounts which the member may receive directly from the attending physician/anaesthetist/pathologist must be submitted immediately to SEDMED for payment. The pre-authorisation number must be clearly indicated on such accounts. See comments on INVOICES/ACCOUNTS below.
- It remains the responsibility of the member to ensure that all payments are made promptly. If a member is in doubt as to whether or not an account had been paid, SEDMED should be contacted without delay.
Invoices/Accounts
Although SEDMED through PPSHA issues pre-authorisation for hospital treatment and procedures and therefore accepts full responsibility for the payment of all related accounts, this does not absolve the member from the personal responsibility of ensuring that all relevant invoices are in the possession of SEDMED or PPSHA by not later than the end of the 4th (fourth) month following the date on which the service was rendered. It is recommended that members discuss the hospital event with the relevant facility and make contact with all the parties who are or were involved to ensure that all invoices will be presented to SEDMED/PPSHA (or the member) so that these invoices are all processed in time. These parties could include the hospital, physicians, specialists, surgeons, anaesthetists, pathologists, ambulance services, physiotherapists, dermatologists, etc. Invoices submitted to members must be processed to SEDMED within the time frame allowed for this in order for benefits to be granted.
Travelling
Providing medical aid benefits while beneficiaries find themselves beyond the borders of the territory of the Southern Africa Union (SAU) remains a challenge. SEDMED cannot process the higher costs of medical treatment and medication outside of the SAU territory. It also cannot efficiently and economically deal with the logistics demanded by such an exercise and members must therefore familiarise themselves with the following requirements:
Medical Insurance Requirements
- In terms of SAU Policy Y 30 15 45 beneficiaries travelling beyond the borders of the SAU territory shall take out adequate international medical & travel insurance for the entire period they are away. Sedmed will only cover incidents that are not covered by ARM (T&Cs apply).
- The required international medical & travel insurance should preferably be arranged by SEDCOM through Adventist Risk Management (ARM). Please note that this cover is not provided by or arranged by SEDMED.
- The ARM insurance cover must be requested at least two full weeks prior to the date of departure. The following shortcomings of the ARM insurance policy are to be noted:
- Cover for any pre-existing medical condition is excluded
- Cover is limited to a maximum period of 9 months at a time. If cover beyond 9 months is required the individual needs to make independent additional medical insurance arrangements.
- Beneficiaries over the age of 79 will be charged a higher premium.
- Beneficiaries over the age of 85 are not eligible for ARM cover and must therefore make other insurance arrangements.
- Cover is only available for employees or retirees in the employ of the organisation who are on official business and/or approved travel by the Seventh Day Adventist Church. The policy covers limited vacation and travel only when combined with official business or approved activity.
SEDMED Membership & Cover whilst travelling
- SEDMED membership contributions must be kept up to date during the entire period of absence from the SAU territory, at all times and without interruption and it is the responsibility of the member to provide clear instructions to his/her pay point to continue payment of the required contributions to SEDMED.
- SEDMED membership will terminate immediately if payment of membership contributions is interrupted or terminated for whatever reason and all benefits will be forfeited.
- Payment of medical benefits for which SEDMED may possibly be liable will be limited to the cost structure of comparable medical treatment and medication within the SAU territory in accordance with the rules of SEDMED.
- Once the beneficiary has exceeded the limit of 90 days referred to above, SEDMED will have no further obligation with regard to the payment of any medical aid benefits in respect of such a beneficiary, including chronic conditions. In order to be able to claim any further benefits the beneficiary must first return to the SAU territory for the required treatment or medication subject to the SEDMED membership contributions having been kept up to date as required in 2. above.
- SEDMED reserves the right to ensure that these provisions are not abused.
- Beneficiaries should purchase adequate chronic (CDL and non-CDL) medication before their departure. In order to claim the said medicine in advance, SEDMED must be contacted by the member and requested to authorise Mediscor to approve the provision of medicine in advance. Failure to comply with this process will result in refusal by the pharmacy to provide medicine in advance.