Most of us think about the cost of the doctor or medical specialist, surgery and hospital stay when we look for medical cover, but there are other health care expenses you need to keep in mind. There are a range of diagnostic investigations – scans, scopes and tests – that are needed for the treatment and management of your illness. And these investigations are not always cheap. In fact a single MRI scan can cost you more than 2 to 3 days stay in a private hospital. So your medical aid will cover this, won’t it? Not necessarily. Especially if you are only have a hospital plan.

Benefits for Investigations

Your medical aid has separate benefits for different procedures. This does not necessarily mean that your hospital benefit will cover the cost of certain investigation because you are having it done in hospital. This is where many medical aid members become confused. Your hospital benefit primarily covers your hospital stay, doctor’s fees for treatment in hospital, surgery and certain types of treatment in-hospital. It may also cover the cost of scans, scopes and tests done in hospital if it is for the condition that you have been hospitalised.

But there are several factors that you have to bear in mind. Firstly, did the condition in question require hospitalisation. Or were you only hospitalised for the scan, scope or test? Secondly, your medical aid may only cover the investigation in question from your day-to-day benefit. This means that you have to have day-to-day cover with funds available for these investigations. If you are on a medical aid hospital plan then you may not be covered.

Verify Cover With Your Scheme

Always call your medical scheme and verify whether they will pay for the scan, scope or test in question. Then verify whether this will come from your day-to-day or hospital benefit. Remember that you are the member of the medical aid and the onus is on you to ensure that your scheme will cover any procedure. Your doctor or the private hospital cannot be held responsible if your medical aid refuses to pay for the scan, scope or test.

In fact, if your scheme does not pay for the investigation in question then you can expect a hefty bill after the scan, scope or test is done. For example, just because a colonoscopy or endoscopy is done in a hospital does not mean that your medical aid will pay for it, or that it will automatically be covered by your hospital benefit. Consider the price of the investigation – an MRI scan can cost you R6,000. Sometimes your scheme will cover it in full. Sometimes not at all. Or there may be instances where your medical aid will only pay for half and the rest has to come from your pocket.

PMB Diagnostic Investigation

If your doctor needs to conduct a specific scan, scope or test then ask him/her if this investigation would be part of the prescribed minimum benefits. These are a list of conditions that your medical aid is compelled to cover – both for the diagnosis and treatment. It usually only applies for emergency situations or chronic diseases that are life threatening. It does not usually cover routine screening to verify whether you have the condition or not when you are not considered to be high risk, when there are no clinical signs of a serious condition and you do not report any symptoms.

But a prescribed minimum benefit does not mean that you have the freedom to use your medical aid and expect bills to be covered as you or your doctor please. Your scheme’s medical panel may still assess the situation and decide whether the scan, scope or test in question is necessary. If not, your scheme may refuse to pay for it and your doctor and the hospital may then expect you to pay cash for the investigation.