I will be travelling outside the borders of South Africa. Does TFGMAS provide benefits for healthcare services I receive in other countries?
Cover outside South Africa is limited to countries that accept the South African rand as legal tender and will be according to the Scheme rules. If you are travelling outside the borders of South Africa, you should always take out additional medical insurance cover.
1. What must I do if there is an emergency and someone in my family needs an ambulance?
In an emergency, go straight to hospital. If you need medically equipped transport, call 0860 999 911. This line is managed by highly qualified emergency personnel who will send air or road emergency transport to you, depending on which is most appropriate. If you are admitted to hospital, it is important that you, a loved one or the hospital let us know about your admission as soon as possible, so that we can advise you on how you will be covered for the treatment you receive.
2. Do I have cover if I have a medical emergency and I need to go to a casualty room?
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a health condition that needs immediate medical or surgical treatment, where failure to provide this treatment would result in:
- Serious impairment to bodily functions
- Serious dysfunction of a bodily organ or part
- The person's life being placed in serious jeopardy.
Cover for going to casualty
If you are admitted to hospital from casualty, we will cover the costs of the casualty visit from your Hospital Benefit, as long as we pre-authorise your hospital admission. If you go to a casualty or emergency room and you are not admitted to hospital, we will pay the costs from your available Primary Care Benefits on TFG Health Plus and you will be liable for a portion of the casualty fee on TFG Health.
3. Who do I contact for pre-authorisation?
Before you go to hospital for any planned procedure, you must:
- Call us on 0860 123 077 to pre-authorise your hospital admission at least 48 hours before admission. We will give you information that is relevant to how we will pay for your hospital stay.
- On TFG Health a 30% non-notification penalty fee will apply, if the member does not pre-authorise their admission. Therefore, 70% of the hospital and related accounts will be covered and you will be responsible to pay the difference.
- On TFG Health Plus a co-payment of R2 000 will be levied on the hospital account if pre-authorisation is not obtained, except in an emergency.
4. What is an MRI scan?
MRI is short for magnetic resonance imaging, which is a procedure that creates images of the human body without the use of X-rays. It is an imaging technique used to view internal structures of the body, particularly soft tissue.
4. What is a CT scan?
A CT scan is a special radiographic technique that uses a computer to incorporate X-ray images of the body into a two-dimensional image.
6. Do I have cover for MRI and CT scans?
On TFG Health, MRI and CT scans are covered from the Specialist Benefit, up to a limit of R5 300 per person and will only be paid if you are referred by a specialist or during an approved casualty auth.
On TFG Health Plus, we cover scans up to 100% of the Scheme Rate for in-hospital scans performed in respect of treatment related to an authorised admission, which is subject to referral by a specialist in our Designated Service Provider (DSP) list.
Where MRI and CT scan is unrelated to the admission it will be covered up to a maximum of 100% of the Scheme Rate from the available radiology and pathology benefits. An appropriate Specialist must give a referral.
Note about MRI and CT scans covered under Prescribed Minimum Benefits:
For scans to be covered as Prescribed Minimum Benefits (PMBs), you must submit a scan report after the scan has been done, indicating that the scan is related to a PMB condition the Scheme covers. You or your healthcare professional must fax or email the scan report for PMB review. If the scan report proves that the scan was for a PMB, the account for the scan will be reprocessed and the co-payment (or amount you would have to pay yourself if it is not for a PMB condition) will be paid from the Scheme's Risk benefits.
7. What is a nuclear scan?
A nuclear medicine scan is a test (diagnostic technique) in which radioactive material (called an isotope) is injected into the body and used to highlight the structure of a specific organ or bone to create an image of it.
Nuclear medicine scans in-hospital (TFG Health and TFG Health Plus)
We will pay for the nuclear medicine scan from the Scheme's Risk benefits, during an approved hospital admission
Nuclear medicine scans out-of-hospital
TFG Health - You are covered from the Specialist Benefit, up to a limit of R5 300 per person
TFG Health Plus - We will pay for the nuclear medicine scan at 100% of the Scheme Rate from your available radiology benefits, subject to a sublimit of R30 900 per family, per year.
1. Do I have to get a pre-authorisation number for specialised dentistry?
When you need dental treatment done in a hospital, you have to contact us by calling 0860 123 077 to pre-authorise your hospital admission, at least 48 hours before you go to hospital. It is always better to contact the contact centre beforehand to verify your benefits and to find out if there will be an amount you have to pay yourself (co-payment) and if a particular treatment will be covered.
2. How do I find the details of the doctors in the TFGMAS network?
Log in with your username and password to the member zone. If you are looking for the nearest doctor, go to 'Your Details' on the left of the screen and click on 'MaPS (Medical and Provider Search)'. You can search by healthcare professional name or by area.
3. I need to submit a claim, how do I do that?
Various options of submitting your claims to the Scheme are available to you:
- Download the Discovery app and submit your claims by taking and submitting a photo of your claims, using your smartphone camera
- Send your claims in hard copy to PO Box 652509, Benmore, 2010
- Email your claim to claims@tfgmedicalaidscheme.co.za
4. How do I access my claims statement?
You can obtain your claims statement as follows:
- After a claim has been submitted, an email will be sent to the email address registered with the Scheme to confirm receipt of the claim and the amounts processed and paid.
- Download the Discovery app and use it to request a copy of your claims statement.
- You can also view your claims history using the Discovery App.
- Claim statements may also be viewed and downloaded via the website by logging into the member zone using your username and password.
5. May I cancel my membership with the Scheme while an employee of TFGMAS?
Please enquire with your human resources and payroll office about your employer's conditions of employment and the implications in respect of future employer subsidies that may no longer be available to you if you choose to reinstate your membership with the Scheme at a future date or time.