Emergency / crisis support: /emergency
SADAG 24-Hour Crisis Line: 0800 456 789
If an acute admission has been refused, your PMB limit has been reached, or medications are not being covered — here are the specific steps to take.
In an Acute Crisis Right Now
If you or a family member is in a psychiatric emergency:
- Call SADAG on 0800 456 789 — a trained counsellor is available 24 hours.
- If admission is required, go to the nearest crisis unit or private psychiatric facility. Your scheme must provide PMB emergency mental health coverage — they cannot refuse emergency admission.
- Contact your scheme's 24-hour hospitalisation line. Ask specifically for PMB emergency psychiatric authorisation.
- If pre-authorisation is refused verbally, document the refusal and present at the psychiatric facility anyway. Retrospective authorisation can be obtained — do not delay emergency care because of an administrative dispute.
Common Schizophrenia Medical Aid Crises
1. Acute admission refused or PMB limit exhausted The scheme has declined further inpatient authorisation or states the 21-day PMB limit has been reached.
2. CDL medications charged to MSA Antipsychotics are depleting the savings account instead of being funded under CDL.
3. LAI antipsychotic declined Paliperidone palmitate or another LAI was refused as non-formulary or requiring exceptional-needs.
4. Clozapine monitoring not covered Scheme is applying co-payments to mandatory white cell monitoring tests.
5. Outpatient visits exhausted mid-year The mental-health outpatient benefit (funded from the chronic and day-to-day benefits) is used up; psychiatrist recommends ongoing review.
If Acute Admission Was Refused or PMB Limit Reached
The PMB provides 21 days acute inpatient psychiatric care per year. If the scheme refuses to extend beyond this and the treating psychiatrist states continued admission is clinically necessary:
Step 1: Request written reasons for the refusal from the scheme.
Step 2: Ask the treating psychiatrist to submit an urgent clinical motivation to the scheme's mental health case management team — include current mental state, risk assessment (self-harm, harm to others), and projected stabilisation timeline.
Step 3: Request a peer-to-peer review between the psychiatrist and the scheme's mental health medical advisor. These are often resolved in favour of continued admission when the clinical documentation is complete.
Step 4: If the scheme persists in refusing clinically necessary psychiatric care, file an urgent complaint with the Council for Medical Schemes (CMS). PMB disputes involving patient safety are prioritised by the CMS.
Do not discharge the patient on the basis of a scheme refusal alone if the treating psychiatrist states continued admission is clinically unsafe. The scheme's administrative position does not override the clinician's duty of care.
If LAI Antipsychotic Was Declined
Step 1: Request written decline with clinical reasoning. Step 2: Psychiatrist submits exceptional-needs motivation: prior relapse history on oral therapy, non-adherence documentation, and the specific LAI being requested. Include the number and dates of prior hospitalisations — each hospitalisation represents a real cost the scheme bore, making the economic case for LAI therapy. Step 3: Most schemes approve LAI exceptional-needs when the non-adherence and relapse history is well-documented. Step 4: If declined, escalate to internal appeal then CMS.
If CDL Medications Are on MSA
Contact the scheme's chronic benefits department with the CDL registration number and request reprocessing of claims from CDL. If CDL registration was not completed, register now with the psychiatrist's letter (ICD-10: F20) and request retroactive reprocessing.
If Clozapine Monitoring Is Not Covered
Clozapine monitoring is a mandatory component of clozapine therapy — it cannot be safely provided without regular white cell count checks. The scheme must fund these tests as part of the CDL benefit for clozapine-treated schizophrenia. Write to chronic benefits explicitly citing that clozapine monitoring blood tests are a required component of CDL-covered pharmacological treatment and must be funded at the CDL benefit level without co-payment.
If Outpatient Visits Are Exhausted
When your outpatient mental-health benefit runs out: 1. Ask the psychiatrist to motivate for additional visits through the scheme's mental health case management programme. 2. Some schemes offer extended visit benefits for CDL-enrolled members in a mental health disease management programme. 3. If the scheme declines, escalate to the CMS citing the clinical necessity of ongoing psychiatric review for a CDL condition.
Triage Table
| Situation | Priority | Action |
|---|---|---|
| Emergency admission refused | Urgent | Go to facility; demand PMB auth; CMS if blocked |
| PMB 21-day limit reached, still unstable | Urgent | Psychiatrist motivation + peer-to-peer review |
| CDL meds on MSA | High | CDL reregistration + reprocessing request |
| LAI declined | High | Exceptional-needs with relapse history + CMS if needed |
| Clozapine monitoring not covered | High | CDL dispute letter to chronic benefits |
| Outpatient visits exhausted | Medium | Mental health DMP enrolment + CMS appeal |
Escalation Contacts
SADAG (24-hour): 0800 456 789 | www.sadag.org Council for Medical Schemes (CMS): 0861 123 267 | www.medicalschemes.org.za AURA Emergency: /emergency
Talk to Eldon
Get urgent help with your cover situation →
This page is general information about medical schemes. It is not medical advice: speak to a healthcare professional about your own treatment. Medical aid and gap cover advice is given by Eldon de Waal, a Supervised Representative of Approach Administration (FSP 23579).