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When is an emergency an emergency? PMB definitions

Written by Vicki Pinkney-Atkinson.

Is this a first year philosophy question? No, it’s a real problem that I am facing right now.

The answer is that it depends on whether you want your medical scheme to pay for it in full or not.

Fact: All medical emergencies are PMBs which require full payment from you medical scheme.
However, like Orwell’s Animal Farm some emergencies are more equal than other. You might have an emergency and your healthcare professional can diagnose it is an emergency. However, that is not enough. The secret is that there are grades of emergency. Only the most important level of emergency will be paid as a PMB.

The test is that it must be serious, it must be sudden and require immediate medical or surgical treatment.

Here is my example.

Last year I was admitted to hospital with meningitis and spent some time in high care. A few days after return to the general ward I had a major bleed from somewhere in my gastrointestinal tract. I awoke in high care being with a “line” going into my heart and being made ready for an endoscope.
I wanted to delay the endoscope but was told: "Your haemoglobin levels are too low and if we dont do it now your condition will be too critical to give you an anaesthetic.” My haemoglobin was 5 rather than around 12 (units don’t matter here).
You can tell I made it through or I wouldn’t be writing this. Only thing is I needed to another emergency colonoscopy the next day. Looking at it from another point of view. At least I had had a few pints of blood by then but I was still bleeding.

Here is the rub. Six months later the hospital claims department is want a co-payment for the endoscopies.
The question is was this a sufficient and necessary emergency?

You let me know what you think while I wait for adjudication.

You need to check your hospital bills and ask questions.

The Medical Schemes Act 131 of 1998 defines an “emergency medical condition” as “the sudden and, at the time, unexpected onset of a health 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 person’s life in serious jeopardy”.

More information Drawn from Council for Medical Schemes CMScript 6 2012

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