Coverage
Covers the medical practitioner cost for in-hospital procedures and specified outpatient procedures. Cover is limited to the percentage of the Medical Scheme Tariff and does not provide for additional costs of prosthesis, materials and medication. It covers the services provided by specialists, general practitioners and medical professionals during the period of hospitalisation.
Casualty Benefit
If you receive emergency medical treatment in a hospital casualty unit, this benefit will cover the treatment costs. Limited to R10, 000 per insured person per annum.
“Emergency” means the sudden and, at the time, unexpected onset of a health condition requiring immediate medical treatment and/or operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body
parts, or death.
Sub-limitation
This covers you for charges above most limits for in-hospital procedures and treatment which exceeds limitations imposed by the medical scheme.
The Medical Aid Scheme sets sub-limits on Medical Aid benefits. These limits can be set per procedure type in order to manage exposure.
Co-payment
If you are required to pay an upfront fee, before medical assistance is administered (e.g. MRI scan), co-payment can help you cover the cost.
“Co-Payment” means a stated amount imposed as a co-payment or deductible by a medical scheme. A co-payment or deductible must be indicated in the rules of the medical scheme as approved by the Council for Medical Schemes.
A co-payment or deductible as a result of an agreement between a member and a medical scheme will not qualify for benefits in terms of this policy.
Premium Waiver
In the event of the total and permanent disability of the principal member of the medical scheme due to an accident, the benefit will pay the medical aid premiums at the time of the incident for six months within the stated limitations. This benefit will commence on the first day of the following month from the date of the incident.
The Premium Waiver Benefit terminates at the earlier of the member reaching the benefit expiry age of sixty-five. Claims submitted before the benefit expiry age will be assessed and paid, but claims after the benefit expiry age will not be accepted. The Premium Waiver Benefit is not available on the Senior package.
Oncology
This benefit provides cancer treatment in a private hospital subject to the sub-limitations and co- payments imposed by the medical scheme and covers charges for treatment subject to a defined list of biological Cancer drugs for specific oncological conditions and/or sub-groups of cancer.
This benefit provides for Cancer treatment in a private hospital subject to an excess of R200,000 per Treatment Cycle.
Treatment includes hospital expenses, chemicals, medication and out-patient radiotherapy or chemotherapy and excludes the cost of specialist consultations.
Hospital Excess Cover
Covers the excess amount which exceeds the limitations applicable under the Medical Aid option and/or above the hospital limitation. Hospital Excess Cover is subject to a minimum excess of R200,000.
Limits
All benefits are limited to R210,580 per insured person per annum.
