Frequently Asked Questions
Questions on membership
Membership of Engen Medical Benefit Fund is restricted to full-time, permanent employees of Engen, and participating employers.
Legal dependants can include a member’s spouse or partner, dependent children, stepchildren or children in the member’s legal custody, including dependent grandchildren. A member’s adult children can remain registered on the Fund if they are full-time students and/or financially dependent on the member. For example, a mentally or physically disabled child who is not employed can be a dependant, as well as financially dependent parents or parents-in-law who earn less than a certain amount.
If you divorce or end a domestic partnership, your ex-spouse or ex-domestic partner can no longer remain a dependant on your membership. Let us know so that we can cancel your ex-spouse or ex-partner as your dependant. If we unknowingly pay their claims, you may have to pay the cost of those claims back to the Fund. Please speak to your HR Department to remove a dependant.
All dependants who are 21 years and older contributions are charged adult dependant rates, with the exception of disabled children, who are charged child dependant rates until they turn 26.
To keep dependants who are not disabled registered on your membership, we require yearly verification of either full-time studies or a sworn affidavit indicating financial dependency on you and three months’ bank statements or salary slips. You must send this information to firstname.lastname@example.org. If you do not do this, your dependant’s membership will end.
The Medical Schemes Act No 131 of 1998 allows medical schemes to impose a penalty (an additional fee) on late joiners. A late joiner is any member or adult dependant older than 35 years who has not had medical scheme cover for a number of years. Late joiner fees discourage people from joining a medical scheme only when they’re old or sick, which is not fair to existing members who have contributed for many years.
A late joiner fee is calculated as a percentage of the risk portion of your medical scheme contribution and does not include the savings portion of the contribution (where applicable). The additional fee that is charged depends on the number of years a person has not been covered by a medical scheme. This is calculated as follows:
Age when applying minus (35 years + creditable cover*) = total years without cover**.
*Creditable cover is medical cover the member had while they were over the age of 21 and only relates to registered South African medical schemes. In other words cover on foreign schemes and cover as a dependant under the age of 21 is not recognised as creditable coverage.
**The total years without cover are matched to the maximum penalty that can be charged to determine the amount of the late joiner penalty. Schemes can determine the level of penalty and don’t have to charge the maximum, but cannot charge more than the maximum.
|Total years without cover||Maximum penalty|
|1 – 4 years||5% of the risk portion of the contributions|
|5 – 14 years||25% of the risk portion of the contributions|
|15 – 24 years||50% of the risk portion of the contributions|
|25 years or more||75% of the risk portion of the contributions|
The following example shows how a late joiner penalty works:
Thabo is 48 years old. He joined his company’s medical scheme at the age of 21 years and remained a member on that scheme for 10 years. He then moved overseas and was not a member of a South African medical scheme for 17 years. He recently returned to the country to work for Engen and will join Engen Medical Benefit Fund.
Thabo is a late joiner. His late joiner fee will be calculated as follows: 48 (Thabo’s current age) minus (35 years + 10) = three years uncovered.
According to the table, 3 years without cover equals a 5% late joiner penalty. Engen Medical Benefit Fund may request Thabo to pay an additional 5% on his monthly contribution in fees. So, as a late joiner, Thabo may be required to pay up to 5% more than other members of Engen Medical Benefit Fund.
Questions about claims
This is a set of defined benefits for certain medical conditions that all medical schemes must provide according to the Medical Schemes Act. This ensures that all members have access to certain minimum healthcare services The conditions that are covered as Prescribed Minimum Benefits were selected because they are common and often life threatening. Although these benefits must be provided to all members, the Fund can apply certain clinical criteria to your treatment and ask you to use a designated service provider (DSP). Click here if you have questions about Prescribed Minimum Benefits.
A Designated Service Provider is a healthcare professional (such as a doctor, pharmacist or hospital) the Fund has a payment arrangement with. In the case of Prescribed Minimum Benefits, Designated Service Providers are the Fund’s first choice when members require diagnosis, treatment or care for a Prescribed Minimum Benefit condition. The Fund appoints Designated Service Providers so that the treatment received for PMB conditions is appropriate and delivered at a reasonable cost.
For speedy and successful claim processing, the claim should include the following:
- ID number or patient's date of birth
- Membership number
- Doctor's practice number
- Date of service
- ICD-10 code
- Tariff code
- Amount charged.
- The membership number is verified
- The patient's information is verified
- The claim is captured
- The claim is assessed and verified against the benefit rules
- The claim is rejected or approved for payment.
If information that should be on a claim is missing or unclear, we reject the claim. The “Reason code” column on your claim statement will indicate the reason for the rejection. For example, Reason code 59 means the tariff code was either incorrect or was not supplied. If the reason for not paying the claim is a lack of information, get the right information and resubmit the claim.
The reason codes tell you more about the claim that was paid; for example, that it was paid from the Chronic Illness Benefit. If the claim was not paid, the pay codes will indicate why it was not paid. It is important to read the description we provide for every pay code on your claims statement, as you may be required to submit additional information before we can pay the claim.
ICD-10 codes appear on your healthcare professionals accounts. ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems. The ICD-10 codes tell us about the condition you’re being treated for, so the Scheme can settle claims correctly. The Medical Schemes Act requires medical schemes to treat all information about members’ conditions with the utmost confidentiality. The ICD-10 codes for your diagnosis will never be shared with anyone else, including your employers or family members.
You can track your claims online if you have internet access and are registered on the Engen Medical Benefit Fund website. To ensure your data remains secure at all times, claim tracking occurs in a secure, password-protected environment. Follow these simple steps to register:
- Go to www.engenmed.co.za
- Click on Register
- Follow the prompts to register a username and password.
Once you have registered, you can log in and access your information in a secure environment.
Once you are logged in, you can view your:
- Claims and monitor their status
- Membership details
- Edit your contact details.
Claims must be submitted within four months. Older claims will be considered expired and will not be paid
- Remember to have full cover for planned PMB in-hospital care, you must go to a DSP GP or Specialist and be admitted by them to a hospital in the KeyCare Network.
- Prescribed Minimum Benefits in- and out-of-hospital (full cover when the services of DSP providers are used)
Questions about pre-authorisation
Pre-authorisation for planned hospital admissions is a quick and simple process to ensure you receive the appropriate treatment for your condition, while costs are kept as low as possible. Pre-authorisation also gives you an opportunity to find out what your available benefits for the procedure or treatment are, to consider the benefits of using a network provider and to plan for any out-of-pocket expenses.
First, you need to confirm the date of the procedure and the hospital where the procedure will be performed or the treatment given. Then confirm the relevant tariff and ICD-10 codes. The treating doctor’s rooms should be able to assist you with this information. Once you have all the information, call 0800 001 615 and follow the voice prompts. The customer care consultant will also explain the benefits of using a network specialist.
For an emergency admission, you or the hospital must call 0800 001 615 for pre-authorisation. Business hours are from 07:00 to 17:00 Monday to Friday. If it’s not possible to call during business hours, you still have 48 hours from the first business day following the admission to obtain authorisation. Obtaining the necessary authorisation ensures that your claims will be settled correctly.
In an emergency admission, we don’t expect you to shop around for a network specialist, given that your time will be limited. Prescribed Minimum Benefit claims, such as claims arising from a stroke or heart attack, will be covered in full, while claims that are not classified as Prescribed Minimum Benefits will be covered at the Fund rate.
Questions on contacting the Fund