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 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 500% of the medical scheme tariff (MST). The shortfall cover amount provided is calculated as: doctors’ and specialists’ charges (limited to 5 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 5 times MST) less the greater of either the medical scheme’s contribution to these costs or the MST amount.
3. Internal Prosthesis and Artificial Joint Cover: Shortfall cover of up to R35 000 per policy per calendar year for internal prostheses such as artificial joints. This benefit will pay for the co-payment or the shortfall in the costs of the internal prosthesis that is not covered by your medical scheme when the scheme’s annual limit is reached. No cover is provided for intraocular lenses and protheses that are not replacing a body part such as cardiac stents.
4. Co-payments Cover: Full cover for upfront co-payments that are charged by medical schemes 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).
5. Non-DSP Co-payment Cover: Up to R10 000 each year for each policy (one claim per year) is provided to cover the co-payment when using a hospital outside of the medical scheme’s approved Designated Service Provider (DSP) network.
6. Enhanced Cancer Cover: In addition to the Gap and Co-payment benefits that cover the shortfalls on cancer treatment, additional cancerspecific cover is also provided.
6.1. Cover for the co-payment as levied by medical schemes when the member’s total annual cancer treatment limit is exceeded. This cover is subject to a maximum co-payment of 25%, which can be used to cover general treatment and the costs of biological drugs and specialised treatment. This benefit is paid subject to registration on the medical scheme’s cancer treatment programme.
6.2. Where a cancer treatment cost limit is imposed and where no further treatment is funded by the medical scheme, this benefit will subsidise 20% of the ongoing treatment costs. This benefit can be used to cover general treatment and the costs of biological drugs and other specialised treatments.
6.3. Up to R20 000 cover is provided for cosmetic breast reconstruction, for surgical costs that are not covered by the medical scheme for breast reconstruction of a non-affected breast in the event of a single mastectomy resulting from cancer. This cover applies to cancer diagnosed after the commencement of cover and after completion of the 12-month waiting period. Any subsequent reconstructions or replacements required after the first one, are not covered.
7. In-hospital Dentistry Expense Shortfall Cover: This benefit covers in-hospital dental treatment as covered by the policyholder’s medical scheme and is calculated as follows: This benefit includes combined dentists, doctors and specialists charges, limited to 5 times Medical Scheme Tariff (MST) less the greater of either the medical scheme’s contribution to these costs or the Medical Scheme Tariff amount.
8. Emergency Room Cover: Accident-related charges incurred for in-hospital casualty ward treatment are covered. This benefit includes the facility fee, consultations, medications, ward stock, radiology and pathology and it is limited to R20 000 for each 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.
9. 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.
10. Lump Sum Cancer Cover: R30 000 is payable in the event of first-time stage 2, 3 or 4 cancer diagnosis. Payment of this benefit is also subject to the insured’s registration on the medical scheme’s oncology treatment programme. This is, however, a fixed benefit payment and is not reliant on verification of actual treatment costs. This cover excludes skin cancer and applies to cancer diagnosed after the commencement of cover and after completion of the 12-month waiting period.
11. Accidental Dentistry Cover: Accidental tooth fracture cover, for tooth fractures caused from 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 medical scheme. This benefit will pay up to R19 250 per policy per calendar year.
12. 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.
13. 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.
14. Medical Scheme and Gap Policy Premium Cover: This cover is paid as a lump sum benefit equal to 12 times the policyholder’s combined Liberty Gap Cover and medical scheme premiums at the time of the claim incident. This benefit is subject to a policy limit of R100 000 and is payable following the accidental death or accidental permanent disability of the policyholder. Cover for this benefit ceases at age 65.