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 R150 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 April 2018 in line with the regulation announcement.)
- In-hospital Cover: The policy covers any 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.
- 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 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.
- 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 is payable after the exhaustion of the medical scheme specified limit or threshold has been exceeded. Cover for intraocular lenses are excluded.
- 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).
- Non-DSP Co-payment Cover: Up to R8 600 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.
- Enhanced Cancer Cover: In addition to the Gap and Co-payment Gap benefits that cover the shortfalls on cancer treatment, additional cancer-specific cover is 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 20%.
6.2 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.
- 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).
- 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. 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 R10 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.
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.
- Lump Sum Cancer Cover:
R25 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.
- 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 250 per tooth, irrespective of cover provided by the medical scheme. This benefit will pay up to R15 750 per policy per calendar year.
- 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 in respect of accidental permanent disability.
- Trauma Counselling Cover: Trauma counselling cover of R750 per session, subject to an annual policy limit of R25 000.
- Medical Scheme and Gap Policy Premium Cover: This benefit covers the actual medical scheme and Liberty Gap Cover premium amounts in the event of the policyholder’s death or permanent disability. Cover is subject to a maximum payment of R6 500 per month, for three consecutive months. Cover ceases at age 65.