Definitions

We hereby attempt to provide you with clarity regarding certain statements or words used by SEDMED on this website and/or in it's Rules and membership guide.

Approval or Authorisation

Means prior written approval.

Chronic disease

A chronic disease is a medical condition from which a patient suffers over an extended period of time and in respect of which the patient requires continuous medication and/or treatment.

Chronic medicine

Chronic medicine is prescribed medication to be used by a patient on a continuous basis over an extended period of time in order to preserve a reasonable quality of life.

ChronicDiseases (CD)

The Government has identified a list of 26 diseases in respect of which medical schemes must pay 100% of the cost of diagnosis, medication and treatment without any annual limit.

Compensation Commissioner (injury while on official duty) or Road Accident Fund (RAF)

If a member and/or dependant is injured in a road accident,the member must as soon as possible inform SEDMED of the incident and register a claim with the RAF. In such an event SEDMED may cover the cost of treatment and medication, but the member must upon receiving compensation relating to his/her medical expenses from the RAF, refund SEDMED for all medical expenses incurred on behalf of the member and/or dependant.

If a member or dependant is injured whilst carrying out official duties, the employing organization must immediately inform SEDMED of the incident and register a claim with the Compensation Commissioner. In such an event SEDMED is not responsible for covering the cost of medication or treatment.

Day clinic and hospital day ward

Day clinic and hospital day ward is a facility which allows for a patient to be discharged on the very same day a procedure is done, eliminating an overnight stay.

Dependant

  • Is a member's spouse, dependent child or immediate family who is dependent upon the member and in respect of whom the member is legally liable for family care and support.
  • A dependent child means the member's natural child, or a stepchild, or legally adopted child or a child in the process of being legally adopted or a child in the process of being placed in foster care, or a child for whom the member has a duty of support or a child who has been placed in the custody of the member or his/her spouse and who is not a beneficiary of any other medical scheme.
  • To qualify as a dependant, the child:
  • must be under the age of 21, or older if he or she is permitted under the rules of the Scheme to be a dependant;
  • must not be a member or a registered dependant of a member of a medical scheme;
  • must be financially dependent on the member;
  • must be a full time student at a recognised institution and be under the age of 26 years and be financially dependent on the member, as determined by the Board, for a period not exceeding 12 (twelve) months at a time, or a period determined by the Board from time to time;
  • must be a child who, due to mental or physical disability, is dependant upon the member while such disability continues. Documentary proof of dependency as outlined above is required when registering a dependant, including certified copies of ID, student registration or certificate of disability. 

Designated Service Provider (DSP)

A DSP is the provider of services with whom SEDMED has contracted to provide certain services and whose services must be used by the member whenever such services are required. DetailsofsuchDesignatedServiceProvidersaregivenbywayofspecialcircular letters from time to time.

Dispute

To question whether a decision made or action taken, or the lack thereof, by the Scheme or an officer of the Scheme is correct and/or valid and/orfair.

Emergency

An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.

Employee

A person or group of persons in the regular and full time employment of an employing organization within the Republic of South Africa, Namibia, Lesotho or Swaziland existing in terms of the Constitution of the Southern Africa Union Conference of Seventh-Day Adventists, said person being required to work on a regular basis for at least 37.5 hours per week and also to be a member of the Seventh-Day Adventist Church in good and regular standing.

Employer

The Seventh-day Adventist Church in the Republic of South Africa, Namibia, Lesotho or Swaziland or any of its recognised sub-organisations and any other employer or employer group within the Seventh-day Adventist Church as determined by the Board.

General waiting period

A period during which a beneficiary is not entitled to claim any benefits.

Generic medication

Generic medication is medicine that contains the same active ingredients as patented medicines and is capable of substantially the same performance. Generic medicines are manufactured following the lapsing of patent registration and are usually cheaper.

Hospital related costs

Hospital related costs are all costs incurred in respect of a hospital event as defined below, including the fees of the attending physician/surgeon, anaesthetist, pathology services, X-rays, theatre costs, blood transfusions and medicines associated with the hospital event and used while the patient is being treated in terms of said definition. For all of the following procedures/treatments SEDMED ALWAYS REQUIRES pre-authorisation or post- authorisation in the event of an emergency(see pre-authorisation definition below)

Hospital related event (HRE)

HRE are treatments or procedures requiring the patient to remain in hospital overnight. The following procedures (also requiring pre-authorisation to qualify for 100% benefits), would be regarded as hospital events but should, preferably, be carried out in a day clinic, day ward of a hospital, doctor's rooms or the out patient section of a hospital even though the patient would not, normally, stay overnight in the relevant facility:
  • Biopsy procedures
  • Colonoscopy
  • Direct Laryngoscopy
  • Drainage of an abscess or cyst 
  • Ear Nose and Throat (ENT ) procedures
  • Excision of a nailbed
  • Excision of benign skin lesions
  • Gastroscopy
  • Gynaecological procedures
  • Injection of varicose veins
  • Intravenous administration
  • of bolus injections of
  • antibiotic courses
  • Laser eye treatment
  • Neurology procedures
  • Opthalmic procedures
  • Orthopaedic procedures
  • Periodontal mucoperiostal
  • Flap surgery
  • Radiology, including x-rays, scans,  scopes & angiogram (pre-authorization for x-rays only is not required)
  • Removal of buried dental roots, including impacted or wisdom teeth
  • Sigmoidoscopy
  • Surgical removal of plantar warts
  • Urological procedures
  • Sterilization & Vasectomy 

Non-Chronic Diseases (Non-CD)

SEDMED has identified a list of 40 diseases in respect of which SEDMED will pay 80% of the cost of diagnosis, medication and treatment without any annual limit. Authorisations for Non-CDmedicationisonlyvalidforamaximumperiodof12monthsatatime. Afterthe expiry of the authorisation period, and if the sickness/condition has not been cured, a new authorisation will be provided by SEDMED.

Out of hospital costs:

Out of hospital costs are the costs of all consultations, procedures or treatment by physicians, dentists, physiotherapists and the like, in their consulting rooms, including outpatient treatment, and not forming an integral part of a hospital event as defined above and including eye testing and spectacles (see relevant section on spectacles)

Outpatient

Outpatient is a patient who visits a hospital for treatment and who is discharged without staying overnight. Costs so incurred would be viewed as out of hospital costs. Normal benefits payable would be 75%.

Over the Counter products

Over-the-counter (OTC) products are medicines sold directly to a consumer without a prescription from a healthcare professional, as compared to prescription drugs, which may be sold only to consumers possessing a valid prescription.

Pre-authorisation

Pre-authorisation for all Hospital Related Events (HREs) is required prior to undergoing any treatment or procedure, including treatment or a procedure in a day ward of a hospital, day clinic or doctor's rooms. Pre-authorisation must be obtained at least 24 hours prior to admission or treatment. In the event of an emergency, post-authorisation must be obtained on the first working day following admission or treatment. For all after hours emergencies the SEDMED emergency numbers (071 872 2025 or 072 642 2351) may be called for assistance.

Prescribed Minimum Benefits (PMB's)

Prescribed Minimum Benefits (PMB) is a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services and consists of provision for the diagnosis, treatment and care cost of:
  1. the diagnosis and Treatment Pairs listed in Annexure A of the Regulations to the Act, subject to any limitations specified therein; and
  2. any emergency medical condition.
The aim is to provide members with continuous care to improve their well being. The cost related to the treatment of PMBs must be carried in full by the Scheme and without imposing an annual limit and subject to certain restrictions.

Registration for chronic (CD) and non-chronic (non-CD) medication & treatment:

In order to qualify for the chronic and non-chronic (CD & Non-CD) medication and treatment,chronic CD and non-CD conditions must first be registered with SEDMED or its pharmaceutical management company, Mediscor. See Chronic Medicine & Treatment Benefit below for further details.

The Act

The Medical Schemes Act (Act No 131 of 1998), and the regulations framed thereunder.

Want more information?

Useful Links

Explore

Member Login

Login >>

This website contains a summary of the benefits offered by SEDMED. It does not replace the registered rules of the Fund, but attempts to summarise important information. Therefore, should a dispute arise, the rules of the Fund will apply, and not this website.

This is ultimately your medical fund and therefore you need to know how it operates, how to utilise it responsibly and how you can benefit from it. Please refer to your membership guide and this website to obtain information about your overall health care benefits.