Does medical aid cover emergency dental treatment in South Africa?

It depends on the type of emergency and on your specific plan. A genuine medical emergency needing hospital admission is generally covered under the law’s prescribed minimum benefits. Ordinary urgent chairside treatment, such as a bad toothache, an abscess or a lost filling, is usually paid from your day-to-day or savings benefit instead, like other basic dental treatment.

In short

• A defined legal list called prescribed minimum benefits must be covered by every scheme, in full where you use the scheme’s designated service provider, though a co-payment can apply otherwise. Routine dental pain is generally not on that list.
• Some schemes separately offer their own dental trauma benefit for accident-related injury to the teeth or mouth, each with its own rand limit.
• A toothache or infection that is not from an accident is usually treated as ordinary basic dentistry, paid from day-to-day or savings benefits.
• Hospital admission for a dental procedure, for example under general anaesthetic, generally needs pre-authorisation, except in a genuine life-threatening emergency.
• Cover and limits differ by scheme and by plan, so it is worth knowing what your own plan offers before you need it.

What counts as a medical emergency, in a scheme’s own terms?

The Council for Medical Schemes defines an emergency medical condition as the sudden and unexpected onset of a condition that needs immediate treatment, where delay could cause serious or lasting harm to the body. This is the legal definition behind the prescribed minimum benefits that every scheme must cover, in full when you use the scheme’s designated service provider and possibly with a co-payment otherwise, and it is a narrower idea than how most people use the word “emergency” for a bad toothache.

Are prescribed minimum benefits relevant to a bad toothache?

Prescribed minimum benefits cover a defined list of specific conditions, a list of chronic conditions, and any genuine medical emergency as defined above. Ordinary toothache, an abscess or a broken filling are generally not on the defined list, so cover for them depends on your plan’s own dental benefit rather than on this legal minimum. A small number of oral conditions do appear on the list, but this is the exception rather than the rule for everyday dental pain.

How do dental trauma benefits work?

Some schemes offer a separate, defined benefit for injury to the teeth or mouth after an accident, generally for a limited list of items such as dental appliances and their placement, and usually provided treatment starts within a set number of days of the injury. This is a scheme-specific, optional benefit rather than a legal requirement, so whether it exists, and its rand limit and time limit, all depend on your own scheme and plan. Where the cost of treatment goes beyond the benefit, the balance falls to the patient.

What about a toothache or infection that did not come from an accident?

Most urgent dental treatment of this kind, such as treating an infected tooth or replacing a lost filling, is billed and paid the same way as other basic dentistry, generally from your medical savings account or day-to-day benefit. If that benefit is used up for the year, you may need to pay for the treatment yourself. Can I use my medical savings account for a check-up or a filling? explains this in more detail.

Does emergency dental treatment in hospital need pre-authorisation?

Generally, yes. Most schemes require pre-authorisation for hospital admission and for sedation in the dental rooms, though the usual penalty for missing pre-authorisation does not normally apply to a genuine emergency or a prescribed-minimum-benefit admission. A co-payment for hospital admission still commonly applies, and the amount varies by scheme and plan. Where possible, phone your scheme, or contact the practice, before you go to hospital. In a genuine emergency, treatment should never be delayed to seek authorisation first.

When should I contact a dentist, and when should I go to a hospital emergency unit?

If you are not sure whether your symptoms need same-day dental care or a hospital emergency unit, the dental emergency guidance on this site, including What counts as a dental emergency?, sets out what to look for. As a general rule, severe pain, a knocked-out or badly broken tooth, facial swelling or bleeding that will not stop needs urgent attention, and swelling that affects breathing or swallowing needs a hospital emergency unit rather than a dentist. Cover for the visit is a separate question from how urgently you should be seen, so do not delay care while you check your benefits.

How do I reach Dr Davies?

During the practice’s normal hours, calls are answered on the practice’s number, and outside those hours, Dr Davies answers her own mobile number, both shown on this site. BRS Dental is not registered with medical aids, so it does not claim from them directly, but reception can help you submit your claim to your medical aid. For a figure for your own treatment, call the practice’s reception, where fees are discussed, and ask for a written quotation after an examination. For anything clinical, contact Dr Davies. If your symptoms match the hospital emergency unit description above, go there first rather than waiting for a dental appointment or a scheme authorisation.