Emergency Room Cover
A sub-limit of R9 000 is applicable. This benefit covers an emergency at any registered emergency, 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 emergency facility if no emergency hospital is available within a 30 km radius.
ACCIDENT / TRAUMA BENEFIT
All costs related to the accidental 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 000 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 room.
CHILD EMERGENCY ILLNESS BENEFIT
This benefit is applicable to children 8 years and younger who require out of normal consultation hours or treatment that can only be done in an emergency room. All costs related to the event will be covered, whether you are liable to pay the costs from your own pocket or your medical scheme pays it from your savings account.
Day-to-day Specialist Consultation Fee
This benefit covers the difference between the medical scheme rate and the rate charged by the specialist for consultation only, up to the available sub-limit of R4 500 per policy, R950 per claim, and 3 claims per beneficiary. This depends on the benefit design of your chosen medical scheme option.
Preventative Care Cover
A sub-limit of R4 000 applies. Claims will be paid up to R800 per claim, limited to 3 claims per beneficiary. The following tests 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.
Appliance Benefit
We will pay up to R5 000 per policy for the difference between what the medical scheme benefit amount and what the service provider charges at R2 500 per claim for the following appliances: hearing aids, wheelchairs, continuous positive airway pressure (CPAP) machines, humidifiers, insulin pumps, glucometers, nebulisers, and Mirena device.
Trauma Counselling
This benefit covers trauma counselling with a registered medical professional after a traumatic event.
A sub-limit of R4 000 per policy applies, R800 per claim for children 13 years and younger, R600 per claim for any dependant 14 years and older, and 3 claims per dependant.
You will be covered within the first 6 months after the incident.