Cover for planned hospital admissions

We cover you for planned hospital admissions. Please call us 48 hours before you go to hospital to confirm your admission.

How we pay the hospital account

We pay the hospital account (the ward and theatre fees) in full at the rate agreed with the hospital. You have cover for a general ward, not a private ward.

How we cover your healthcare professionals

Your doctor or treating healthcare professional’s accounts are separate from the hospital account and are called related accounts. Examples of related accounts include the doctor, anaesthetist and any approved healthcare expenses, (for example, radiology or pathology), that you are billed for during your hospital stay. These expenses are funded from the overall annual limit. Please contact us to pre-authorise your benefits before you receive treatment or extend your hospital stay.

The services performed by selected providers while you are in hospital, will be covered up to a maximum of 150% of the Society Rate. In other words, an amount of up to 50% over the Society Rate will automatically be paid for services you receive in hospital. This applies to GPs, medical specialists, maxilla-facial surgeons, physiotherapists, radiologists and pathologists.

Healthcare professionals are free to set their own rates.

If your healthcare professional charges the Society Rate, we will pay him or her directly. If your healthcare professional charges more than the Society Rate, we will pay you. You will have to make sure you pay your healthcare professional’s the full amount.

If your healthcare professional participates in the Discovery Health network, he or she will be covered in full. You can find a healthcare professional who participates in the Discovery Health payment arrangement by logging in.

Limits, clinical guidelines and policies apply to some healthcare services and procedures in hospital.

Medicine to take home from hospital (TTO)

Medicine on discharge (TTO), is included on the hospital account if it is obtained on the date of discharge. Alternatively it is limited to the Day-to-Day benefit.

Before you go to hospital for any planned procedure, you must:

• See your doctor
• Call us on 0860 002 107 to confirm your hospital admission at least 48 hours before you go to hospital. If you do not confirm your admission, you will be responsible for the payment of all accounts.

When you contact us, give us the following details:

• Your membership number
• When you will be admitted into hospital
• The date of the procedure
• The name and practice number of the hospital or clinic
• Your treating doctor’s name and practice number
• Your diagnosis (ask your doctor for the ICD-10 diagnosis code)
• The procedure name and code (ask your doctor for RPL procedure codes)
• If one of your dependants is admitted, give us their details

Cover will apply based on our rules

We pay medically appropriate claims. Your cover will apply based on our Society Rules, funding guidelines and clinical rules. There are some expenses that you may be responsible to pay while you are in hospital that your benefit does not cover, for example, private ward costs. Certain procedures, medicine or new technologies need separate confirmation while you are in hospital.

Cover for Prescribed Minimum Benefits

For Prescribed Minimum Benefits, we pay hospital admissions for defined conditions in full at our designated service providers.

How we cover your childbirth

We cover childbirth from your Hospital Benefit, including home births done by midwives with valid practice numbers and who are appropriately registered with the Board of Healthcare Funders. You must authorise the childbirth admission to hospital or home birth with us before you go to hospital. Remember to register your baby with us as soon as possible so we can cover your baby.

There are certain limits for childbirth benefits: