Primary Care Benefit
This benefit covers you for the shortfall on the consultation fee when your medical scheme pays their scheme agreed rate up to R5 000 per policy, and R800 per claim.
Primary care service providers include:
• GP Consultations
• Dentists Consultations
• Alternative therapist consultations (Chiropractors, Physiotherapists, Biokineticists, occupational therapists, Homeopaths, and Audiologists – if covered by the medical scheme option you are on.) Subject to OAL.
In-room/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 R6 500 per policy, and R1 500 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.
Emergency Room Cover
EMERGENCY ROOM COVER (REF 1, 2, 3)
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 R2 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
This benefit is applicable to children 8 years and younger who require emergency treatment for illness 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.
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 R8 500 per policy, and up to R1 350 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:
We will pay up to R7 500 per policy for the shortfall between the medical scheme benefit amount (if there is a 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
R10 000 per policy.
Accidental Dental Benefit
Should you require a dental procedure as a result of an accident or injury, this benefit covers you for in-room dental procedures up to R10 000 per policy, and to a maximum of R2 500 per tooth.
