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.
Health insurance regulations place a limit of R160 000 for each 12-month period for the Medical Expense Shortfall benefits payable for each person insured under the policy. This limit applies to all the benefits listed under the Medical Expense Shortfall Cover. (This limit will be increased in 2020 in line with the regulation announcement.)
1. In-hospital Cover: The policy covers the shortfall that exists between in-hospital doctor(s)’ charges and the amount paid by your medical scheme. This shortfall is calculated as the difference between the medical practitioner’s charges (limited to five times the medical scheme tariff), less the higher of the amount payable by your medical scheme or the medical scheme tariff.
2. Out-of-hospital Cover: The policy covers the shortfall between doctors’ out-patient treatment charges and the amount paid by your medical scheme. This covers ±50 out-patient procedures and treatments. This benefit includes cover for CT, PET and MRI scans. This shortfall is calculated as the difference between the medical practitioner’s charges (limited to five times the medical scheme tariff), less the higher of the amount payable by your medical scheme or one times the medical scheme tariff.
3. Internal Prosthesis and Artificial Joint Cover: Shortfall cover of up to R30 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 R9 300 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.
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: (combined dentist and specialist charges up to but not exceeding 5 times the medical scheme tariff) minus (the greater of either the medical scheme’s contribution towards these charges or the medical scheme’s stipulated tariff amount for these charges).
8. Emergency Room Cover: Accident-related charges incurred for in-hospital casualty ward treatment are covered. This benefit covers the facility fee, consultations, medications, radiology and pathology associated during admission to a registered hospital’s casualty facility due to an accident.
This benefit amount does not include cover for items such as crutches, neck braces, knee or ankle guards, slings and other charges relating to the provision of post-treatment protective and recuperative devices. It also does not cover the fees charged by the prosthetists or orthotists. Where a full in-hospital admission follows casualty ward treatment, only the shortfall amount not covered by the medical scheme will be covered.
This benefit will pay up to R20 000 per policy per calendar year and is payable irrespective of whether your medical scheme covered the costs. The shortfall is calculated as the Emergency Room charges minus the amount paid by your medical scheme. 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 benefit covers the actual medical scheme and Liberty Gap Cover premiums in the event of the policyholder’s accidental death or accidental permanent disability. This cover is subject to a maximum monthly amount of R7 500 and is payable for 12 months. Cover for this benefit ceases at age 65.