Focus on the Trauma Benefit

Below is information about focus on the Trauma Benefit

The Trauma Benefit is designed to provide coverage for various day-to-day care and treatment needs that arise following a hospital admission due to specific traumatic events. This benefit is available under the Evolve, Incentive, Extender, and Summit Options. It is important to note that the treatment related to the traumatic event must be authorized to ensure that it falls within the scope of coverage.

Which conditions resulting from a traumatic event are covered?

• Severe burns are covered, but they must meet certain qualifying criteria. These criteria include the severity of the burns and the FIMS* score, which assesses the functional independence of the individual.
• Conditions such as paraplegia and quadriplegia are also included, with coverage contingent upon the FIMS* score.
• Post-traumatic stress disorder (PTSD) that arises from serious reported crimes is covered as well, provided that certain qualifying criteria are met. This includes the necessity of having a case number from the police report.

Additionally, the following conditions are eligible for coverage if the individual has experienced an intensive care unit (ICU) stay of five days or more:

• Conditions resulting from near drowning incidents;
• Cases of poisoning;
• Severe allergic reactions; and
• Both external and internal head injuries.

How do members access the Trauma Benefit?

To access the Trauma Benefit, members must first ensure that the admission for the traumatic event is pre-authorized in accordance with emergency protocols. Following this admission, the treating physician is responsible for contacting the Scheme to obtain authorization for the subsequent day-to-day care associated with the traumatic event. It is essential for the physician to provide a comprehensive treatment plan that outlines the specific care required. This plan may include various services such as wound care for burns, nursing services, visits to general practitioners and specialists, as well as necessary radiology and pathology services.

If you have any questions or require further assistance regarding the Trauma Benefit, we encourage you to reach out to us. You can utilize our web chat feature available on momentummedicalscheme.co.za, send us an email at [e-mail], or contact us via WhatsApp at [phone]. Alternatively, you can call us at 0860 11 78 59 for more information and assistance. *FIMS refers to the Functional Independent Measure Scale, which evaluates an individual's capacity to engage in daily living activities.