Day-to-day Specialist Consultation Fee
This benefit covers the shortfall on the consultation at a specialist outside of hospital (excluding Psychiatrist and Psychologist) up to R5 000 per policy, and R1 000 per claim. This benefit is only applicable to consultation codes 0190, 0191, and 0192. The medical scheme needs to make at least partial payment towards the consultation code mentioned above. Subject to the OAL.
Casualty Benefit
There is a sub-limit of R15 000 for all Emergency Room Cover. This benefit covers an emergency at any registered emergency room, hospital, or casualty facility when you require immediate medical treatment due to an accident and trauma, or illness. We will cover a general practitioner (GP)’s consultation rooms if no other emergency facility is available within a 30 km radius. Ambulance costs are not covered by this benefit.
ACCIDENT / TRAUMA BENEFIT
All costs related to the accident/trauma event will be covered, whether you are liable to pay the costs out of your own pocket or if your medical scheme pays from your savings.
ILLNESS / BENEFIT
All costs related to the emergency illness event will be covered and paid up to R1 500 of the sub-limit, if you are liable to pay the costs out of your own pocket, or if paid from your medical scheme savings. This is applicable to any beneficiary 9 years and older who needs emergency treatment outside of normal consultation hours or treatment that can only be done in an emergency facility.
CHILD EMERGENCY ILLNESS BENEFIT
All costs related to the initial emergency illness event will be covered and paid up to R3 000 per claim of the sub-limit, if you are liable to pay the costs out of your own pocket, or if paid from your medical scheme savings. This is applicable to any beneficiary 12 years and younger who needs emergency treatment outside of normal consultation hours or treatment that can only be done in an emergency facility.
Out of normal consultation hours means 18h00 to 07h00 on Monday to Friday, and all of Saturday, Sunday, and South African public holidays. Subject to the OAL.
Preventative Care Cover
If your medical scheme option makes provision for preventative care, we will pay up to R5 000 per policy, and up to R950 per claim.
The following procedures or treatments are covered: Pap smear, cholesterol test, blood glucose test, flu vaccination, childhood immunisation (Department of Health Formulary) – up to the age of 12 years, bone-density scans, prostate-specific antigen tests, mammogram, and contraceptive implantation only.
Alternatively, if there is no benefit available at the time of claim, up to R500 will be paid towards the following tests and treatments, 2 claims per policy:
Appliance Benefit
We will pay up to R5 500 per policy for the shortfall between the medical scheme benefit amount (if there is a defined rand limit) and the service provider account for the following appliances: hearing aids, wheelchairs, continuous positive airway pressure (CPAP) machines, humidifiers, insulin pumps, glucometers, nebulisers, and Mirena devices.
Trauma Counselling
This benefit covers trauma counselling with a registered medical professional within the first 6 months after a traumatic event, such as but not limited to dread disease, hijacking, and/ or violent crime. We will pay up to R6 000 per policy.
