Diagnosed with Pneumonia? Here's What to Do About Your Medical Aid

Whether you've been diagnosed at the GP or are being admitted to hospital, pneumonia is a PMB condition — your scheme must fund diagnosis and treatment. The key actions are: ensure pre-authorisation is in place, know whether DSP or non-DSP applies, and notify gap cover for in-hospital admissions.

The Honest Starting Point

Most pneumonia cases in otherwise healthy adults resolve with 5–7 days of appropriate oral antibiotics at home. Medical aid navigation for outpatient pneumonia is simple: a GP consultation and a chest X-ray, covered under day-to-day benefit.

Hospital admission changes the picture significantly — specialist shortfalls (pulmonologist, ICU), gap cover activation, and DSP hospital selection all require immediate attention.

Step 1: Confirm the Diagnosis

Pneumonia diagnosis requires at minimum: - Clinical assessment: Fever, productive cough, breathlessness, clinical signs (dullness on percussion, bronchial breathing, crepitations) - Chest X-ray: Confirms lobar or interstitial infiltrate — the definitive diagnostic step. Covered under radiology benefit (PMB acute episode).

Your GP may order additional blood tests for severity assessment (FBC, CRP, procalcitonin, urea, creatinine) — all covered under PMB for the acute episode.

Step 2: Outpatient vs Inpatient — The CURB-65 Decision

Your GP or ER doctor uses the CURB-65 score to decide on admission. If CURB-65 is 0–1, outpatient treatment is appropriate. If 2 or higher, hospital admission is standard of care.

If you are being admitted: Notify your scheme's emergency number immediately or have the hospital admissions clerk call within 24 hours. Emergency admissions do not require prior pre-authorisation but must be notified within 24 hours.

Step 3: Outpatient Management — Confirm Antibiotic Formulary Access

Standard outpatient CAP antibiotics in SA (SATS/NICD guidelines): - Amoxicillin-clavulanate (Augmentin) + clarithromycin (or doxycycline) — dual therapy covering typical and atypical organisms - Amoxicillin — for low-severity CAP in young adults without comorbidities - Levofloxacin or moxifloxacin — for penicillin-allergic patients; reserve fluoroquinolones (higher antibiotic resistance risk)

Generic amoxicillin + doxycycline: R200–R400/course. Generic augmentin: R300–R600/course. All available on most formularies.

Confirm with your pharmacist that the prescribed antibiotic is on your formulary before dispensing. If not formulary, your doctor can request a non-formulary substitution or switch to a formulary equivalent.

Step 4: If Admitted — Immediate Actions

Notify your scheme: Call the number on your medical aid card immediately: "I am being admitted to [hospital] with community-acquired pneumonia (ICD-10 J18.9). This is a PMB emergency admission. Please confirm the admission is authorised and the hospital is a DSP."

Notify gap cover: Even for a standard ward admission, pulmonologist shortfalls are significant. Most gap cover policies accept telephonic notification. Say: "I am being admitted for pneumonia at [hospital] and a pulmonologist will be attending. Please note my gap cover pre-notification."

Confirm DSP status: Your medical aid has a network of DSP hospitals. Admission to a non-DSP incurs a co-payment (typically 20–30% of hospital costs). In an emergency, go to the closest appropriate facility — DSP confirmation is secondary to safety. Call retroactively.

Step 5: Non-Resolving Pneumonia — Escalation

If pneumonia does not respond to initial antibiotics within 48–72 hours (persistent fever, worsening oxygenation), escalation of care is needed:

• Sputum culture and sensitivity to guide antibiotic change (funded under PMB)
• CT chest to exclude empyema (pus in the pleural space), lung abscess, or underlying malignancy
• Bronchoalveolar lavage (BAL) — bronchoscopy if diagnosis is unclear (funded under hospital benefit)
• Legionella antigen, Mycoplasma serology, respiratory viral panel

All diagnostic escalation is PMB-covered in the context of acute pneumonia.

Empyema: If pneumonia causes pus in the pleural space (empyema), chest tube drainage is required — this is a PMB-covered surgical procedure.

Step 6: Vaccination After Recovery

After recovery from pneumonia, discuss vaccination with your GP:

Pneumococcal vaccine: If not previously vaccinated, discuss with your GP. Ask your scheme: "Is pneumococcal vaccination (Pneumovax 23 or Prevnar 13) covered for my age or chronic condition?" Most schemes cover it for adults ≥65 or those with chronic disease; younger healthy adults typically pay OOP.

Influenza vaccine: Annual influenza vaccination is the most cost-effective pneumonia prevention measure. Most schemes cover this.

Repeat chest X-ray: A follow-up chest X-ray 6 weeks after discharge is standard practice to confirm resolution and exclude an underlying mass (particularly in smokers ≥50). Confirm it is covered under your radiology benefit.

HIV-Positive Members — PCP Alert

If you are HIV-positive with unknown or low CD4 count: - PCP must be excluded at diagnosis — the treatment (high-dose co-trimoxazole) is different from bacterial CAP antibiotics - LDH level (elevated in PCP), CT pattern, and BAL confirm PCP - PCP treatment funded under HIV CDL + PMB - Ensure you are on co-trimoxazole prophylaxis if your CD4 is <200 — this is funded under your HIV CDL

Key Calls to Make

Talk to Eldon

Pneumonia is PMB-covered from day one of diagnosis. AURA verifies gap cover is activated for in-hospital admissions, confirms DSP hospital status, and ensures follow-up chest X-ray is correctly pre-authorised as a PMB monitoring test.

Review your plan for respiratory illness coverage →