Hospital cover
The Hospital Benefit covers you if you are admitted to hospital and Discovery Health has confirmed your admission and treatment.
We cover you in hospital for emergency and planned hospital admissions. In an emergency, go straight to hospital but call us or get someone to call us within 12 hours. For planned hospital admissions, please call us 48 hours before you go to hospital to confirm your admission.
For us to pay your costs, you must have us confirm your admission beforehand
Cover for all the costs while you are in hospital is not automatic. When you know you are going to be admitted to hospital, you need to tell us beforehand (the contact details are below). You must confirm your admission to hospital at least 48 hours before you go in.
We need to know so we can manage your costs in the best way, and give you information that is relevant to how we will cover your hospital stay. If you do not confirm your admission, we will only pay 70% of the costs that we would normally cover.
We may not pay for your treatment in full
Cover is subject to our rules
Once we confirm your hospital admission, we may not pay for the treatment in full. Your cover is according to our scheme rules, funding guidelines and clinical rules. You can find out more about our clinical rules on Do We Cover.
There are some expenses you may incur while you are in hospital that the Hospital Benefit does not cover, for example private wards. Certain procedures, medicines or new technologies need extra benefit confirmation while you are in hospital.
We only pay for medically appropriate hospitalisation
We pay only medically appropriate claims from the Hospital Benefit.
We will not always cover the full cost of your healthcare professionals
Your healthcare professionals’ accounts are separate from the hospital account. Healthcare professional accounts may include specialist accounts and other related accounts, for example accounts from a:
- surgeon,
- anaesthetist,
- pathologist or
- radiologist.
Healthcare professionals are free to set their own rates:
- If they charge the Discovery Health Rate, we will pay them directly.
- If they charge more than the Discovery Health Rate, we will pay you. You will be able to see this on the claims statement we send to you. You will have to make sure you pay your healthcare professionals the full amount.
- If your specialist has agreed to charge the Premier Rate, we will pay the specialist directly.
We cover the cost of specialists who charge the Premier Rate
If you use specialists who charge the Premier Rate, you will not have to pay from your pocket the difference between what the specialist charges and what we pay for procedures and consultations. The Premier Rate is where we have agreed with specialists to pay them directly. You will always be charged at the Scheme’s agreed rate. To find out if your specialist charges the Premier Rate, you can contact us.
On the Classic Plans, you have a wider group of specialists
with whom you can consult and still have full cover. These specialists charge what is called the Classic Direct Rate. We pay these specialists directly so you will not have to pay anything from your pocket if you see them as part of an approved hospital admission.
If you do not go to a specialist who charges the Premier Rate or Classic Direct Rate, your choice of Health Plan will decide the most we will pay for your related claims in hospital:
| Classic Plan | Up to twice the Discovery Health Rate (200% of the Discovery Health Rate) |
| Essential Plan | Up to the Discovery Health Rate (100% of the Discovery Health Rate) |
We may pay you
If your doctor charges higher than the Discovery Health Rate, we will pay you and you will be responsible for paying the doctor directly.
Cover for Prescribed Minimum Benefits
For Prescribed Minimum Benefits, we pay admissions for approximately 270 defined conditions in full if you have treatment at one of our Designated Service Providers (our choice of hospitals or healthcare professionals). If you do not use our Designated Service Provider you may have to pay the difference between what the healthcare professional charges and what Discovery Health pays.
More about how we pay for Prescribed Minimum Benefits
