A. Medical Expense Shortfall Cover
The policy covers doctor and specialist treatment charge shortfalls that are not covered in full by your medical scheme. Cover is also provided for medical scheme co-payments that are levied. Together, these are known as the Medical Expense Shortfall Cover.
In any 12-month period, each individual insured under the policy has R165 000 Medical Expense Shortfall cover. This is the current maximum permitted Medical Expense Shortfall cover under the South African health insurance regulations. This limit will be increased in line with the regulations on the 1st of January each year.
1. In-hospital Cover: Shortfalls are covered on doctors’ and specialists’ charges of up to 300% of the medical scheme tariff (MST). The shortfall cover amount is calculated as: doctors’ and specialists’ charges (limited to 3 times MST) less the greater of either the medical scheme’s contribution to these costs or the MST amount.
2. Out-of-hospital Cover: Cover is provided for ±50 out-patient procedures including CT, PET and MRI scans. The shortfall cover amount provided is calculated as: doctors’ and specialists’ charges (limited to 3 times MST) less the greater of either the medical scheme’s contribution to these costs or the MST amount.
3. Co-payments Cover: Full cover for upfront co-payments that medical schemes charge for hospital admissions, scans and certain surgical procedures. Please note that Penalty co-payments that are imposed by medical schemes for not following the rules of the scheme are not covered. Examples of these penalties are amounts due as a result of not obtaining pre-authorisation from the medical scheme for a procedure or consulting a specialist without first obtaining a referral from a general practitioner (GP).
4. Emergency Room Cover: Accident-related charges incurred for in-hospital casualty ward treatment are covered. This benefit will include the facility fee, consultations, medications, ward stock, radiology and pathology and is limited to R20 000 per policy per calendar year. Prescribed medication obtained after leaving the emergency room and subsequent follow ups to the emergency room and the cost of any prosthetic products such as crutches, limb guards or braces or any fees charged by prosthetists or orthotists, will not be covered. To qualify for this benefit you must use the casualty facility within 48 hours of the accident.
5. Robotic Medical Procedure Cover: Cover of up to R30 000 per policy, per calendar year for medical expense shortfalls that arise directly from the use of robotic machinery in the course of in-hospital operative treatment.
B. Health Insurance Cover
The cover items listed below are not subject to the overall regulated Medical Expense Shortfall limit per individual insured, per year.
6. Accidental Dentistry Cover: Accidental tooth fracture cover for tooth fractures caused by an external blow to the mouth. This is provided per individual per calendar year. This cover is payable at a rate of R2 750 per tooth, irrespective of cover provided by the policyholder’s medical scheme. This benefit will pay up to R19 250 per policy per calendar year.
7. Accidental Death and Permanent Disability Cover: A R50 000 lump sum benefit is paid in the event of accidental death or accidental permanent disability. This cover ceases at age 65 for accidental permanent disability.
8. Trauma Counselling Cover: Trauma counselling cover of R750 per session, subject to an annual policy limit of R25 000. This cover is subject to the commencement of trauma counselling within 6 months after being subject to, or a witness of, an act of violence or a traumatic accident, and continuing for no longer than 6 months after counselling starts.
