Inpatient Addiction Treatment Covered By Medical Aid

Medical schemes don’t pay for “rehab” because it sounds worthy — they pay for medical necessity. For detox that means objective risk or complications: prior delirium tremens or withdrawal seizures, heavy benzodiazepine or alcohol dependence, polydrug withdrawal, pregnancy, marked autonomic instability, severe psychiatric symptoms or major medical comorbidity (HIV, TB, cardiac disease). Don’t walk in with a story — bring data. A motivating clinician (psychiatrist or medical doctor with addiction experience) needs to submit a letter that documents diagnosis (use ICD‑10 F10–F19 codes), CIWA‑Ar or COWS scores, recent seizure history, relevant labs (LFTs, U&E, ECG where indicated), urine tox, and a clear statement of why outpatient management risks harm. If you can show imminent medical risk or the need for medical monitoring and medication management, schemes are far more likely to authorise inpatient detox days rather than decline as “non‑essential.”

That gap is common. Insurers separate acute medical care (detox) from longer therapeutic admissions. The clinical fix is to present detox and the therapeutic plan as one integrated episode of care: an initial medical stabilisation phase followed by continued inpatient treatment for risk management, relapse prevention and functional rehabilitation. Your treating psychiatrist or physician should outline explicit daily treatment goals, measurable targets (behavioural risk reduction, medication stabilisation, psychiatric management), and a multidisciplinary plan (nursing, psychotherapy, occupational therapy). Include objective safety concerns — if the patient has severe functional impairment, active suicidal ideation, or an unsafe home environment, note that outpatient care is likely to fail. Ask the scheme’s case manager to consider a phased authorisation (X days for detox + Y days for therapy) or provide a guaranteed approval pending clinical review. If they still refuse, escalate with an urgent appeal and attach the same integrated clinical documentation.

Schemes use classification and coding to limit payment: they may code treatment as "outpatient counselling", place therapists outside the hospital benefit, or classify the admission as “social admission” rather than a psychiatric/medical admission. They may also apply waiting‑period rules for pre‑existing substance‑use diagnoses. Pre‑empt this by insisting that your treating doctor uses the correct ICD‑10 diagnostic codes for substance use disorders (F10–F19), requests hospital admission under a medical or psychiatric admission code, and obtains pre‑authorisation with the exact tariff codes the facility will bill. Ask your scheme for the benefit rules around mental health and substance abuse, whether inpatient mental health days are pooled across dependents, and whether the multidisciplinary team’s fees (psychologist, therapist, physician) fall under the hospital or out‑of‑hospital benefit. Clarify waiting‑period status and any exclusions before admission — if you don’t get a clear answer in writing, get a second clinical opinion and lodge a pre‑authorisation appeal immediately.

Expect three sources of cost: hospital facility tariff, practitioner fees (doctors, psychiatrists, therapists) and medication/ancillary costs. Schemes pay based on their own tariff; if the facility bills above that rate you’ll face a shortfall. Practitioners can bill separately and often charge above scheme rates. To reduce surprises, get a written pre‑authorisation and a guarantee of payment from the scheme that specifies which account lines are covered and at what rate. Ask the facility for an itemised costing estimate and whether they will limit practitioner fees to the scheme tariff. Negotiate a co‑payment cap with the admissions office if possible. If you expect long inpatient days, ask about case‑management meetings with the scheme to re‑authorise and to prevent unexpected mid‑admission denials. Finally, explore whether the treating team can deliver essential therapeutic work under the hospital account rather than as out‑of‑hospital private practice fees — that usually reduces patient exposure.

Move fast and be clinical. First, get the treating psychiatrist or medical officer to submit an urgent peer‑to‑peer motivation to the scheme’s medical advisor with full documentation (clinical notes, CIWA/COWS, risk assessment, lab results). If that fails, lodge an internal appeal immediately and demand the scheme’s rationale in writing. Use your broker if you have one — experienced brokers cut through admin delays. If the admission was emergent and life‑preserving, cite the PMB/emergency provisions and ask for an urgent review. If the scheme still declines, escalate to the Council for Medical Schemes (CMS) and the Office of the Ombud for Medical Schemes with your submission; include the clinical motivation, appeal correspondence and time‑stamped clinical records. While you’re appealing, keep the lines open with the facility — they may agree to defer collection pending resolution or offer a reduced rate to avoid transferring the patient back into an unsafe home environment. Time matters: clinical evidence submitted quickly and a coordinated specialist appeal are the moves that actually get denials overturned.