EssentialMED will settle the claim directly where possible. Some providers expect upfront payment in which case your claim will be reimbursed.
Here's what you need to know.
If you need to submit the claim yourself then simply email your policy number and a copy of the invoice or statement to email@example.com.
Your claim will be processed according to your benefits.
The purpose of the managed process is not to stop you from seeing a doctor but rather to ensure that the unlimited value of the benefit is not being abused.
To preauthorise a hospital procedure, call Africa Assist on 0861 911 011 and identify yourself as an EssentialMED member with your Policy Number. They will guide you further on what information they need.
In general, all Hospital claims for planned procedures need to be pre-authorised at least 48 hours before you can use the benefit. This is a simple procedure where we determine whether the procedure you need is covered under your benefits and whether you still have available amounts left over after previous claims.
Events covered under the Accident Hospitalisation benefit may require immediate hospitalisation or result in the person affected being unconscious or otherwise unable to obtain pre-authorisation. In these events, medical personal will always stabilise a patient before being generally admitted, at which point your next of kin can assist with identifying you and your available medical cover.
If you can't practically pre-authorise a hospital visit due to an accident or emergency then you must inform EssentialMED within 48 hours about the accident event.
When you apply for a new policy there is an underwriting stage where you are asked to disclose your medical history. Certain disclosures may result in condition specific endorsements to your hospital benefits which means that claims related to that pre-existing condition may carry a longer waiting period or be excluded from the policy.
This is because the insurer can't take on a known risk for medical conditions that you are already aware of for the same premium.
Day-to-Day benefits and claims not related to those pre-existing conditions are not affected by this additional underwriting.
Access private healthcare when you need to see a doctor, visit a dentist, get medication or go to hospital.
In general, this is not required. EssentialMED will pay providers directly on the submission and processing of a claim. The provider will either submit the claim or you can yourself on their behalf.
However, there are some providers that force clients to settle their bills before being treated. These claims will be reimbursed according to the benefits.
In general, this is not required. EssentialMED will pay providers directly on the submission and processing of a claim. It is important, though, to understand your benefits and the limits that they cover.
The Medication Benefit, for example, does have medicine on the formulary that may require a co-payment. It is not practical to publish the entire formulary so it is best to ask us, your network doctor or EssentialMED if there is anything specific that you'd like to look up.