We recognise that health professionals play a critical role in helping you improve your health and wellbeing. We have a responsibility to you and the Fund to use our experience, and expertise to help keep your medical cover affordable.
This is why the Fund has entered into arrangements with specialists, GPs and other healthcare providers, ensuring you have limited or no co-payments when you use their services.
You can benefit by using a healthcare professional who we have an arrangement with because we will cover their approved consultations and procedures in full. We pay claims directly to the healthcare professional when we have an arrangement with them.
To be sure you will not have to make co-payments when you use the services of a GP and specialist, you have to make use of the services of one a GP or Specialist in the Fund's designated service provider (DSP) networks.
To be sure all the costs for PMB treatment in a hospital is paid in full, you need to use the services of a GP or Specialist in the Fund's DSP Networks and be admitted to a hospital in the Fund's PMB Network of hospitals.
To search for a service provider that is in our networks and closest to you, click here.
Dentistry is paid from your Medical Savings account (MSA) and the Insured Benefit subject to sub-limits. These limits apply for dental services in- and out-of-hospital.
Hospital admission and treatment whilst in hospital
The details of the authorisation, including possible exclusions, will be emailed to you (if we have your email address and you are requesting the authorisation), your treating healthcare professional and the hospital.
Make sure to clarify any uncertainty you may have with your treating practitioner or the Fund prior to your admission as some procedures, items and medication may not be covered or you may have to pay some of the costs. Should the treating practitioner disregard the terms and conditions of the authorisation, you will remain responsible for the costs incurred.
Where possible, make use of a hospital in the KeyCare Network, specialists and other medical service providers on the Fund's Network lists to optimise benefits and minimise co-payments for treatment while in hospital. Please visit the Fund's website at www.engenmed.co.za to find the nearest Network GP or Specialist to you.
When you need to go to hospital for a planned PMB procedure or treatment, and want the Fund to pay all costs related to the care in full, your admitting doctor must be a DSP GP or Specialist and you must go to a hospital in the KeyCare Hospital Network.
Funding of accommodation in a private ward is subject to a motivation from the attending practitioner and authorisation.
A co-payment applies in the case of elective investigative endoscopies, if these procedures are performed in hospital (Colonoscopy, Sigmoidoscopy, Proctoscopy, Gastroscopy, Cystoscopy, Arthroscopy, Laparoscopy and Hysteroscopy).