IN-HOSPITAL BENEFITS
TARIFF SHORTFALLS
In-Hospital Benefits include cover for substantial tariff shortfalls, co-payments or sub-limits, co-payment and deductibles and shortfalls from sub-limits arising from in-hospital consultations and procedures.
- Tariff Shortfalls
- Up to a maximum compensation limit of five times the Medical Scheme tariff fee if designated service providers are used.
- Limited to a maximum compensation limit of one times the Medical Scheme tariff fee if a non-designated service provider is used on a Medical Aid Plan driven by a designated service provider group network OR where treatment has been provided for maxillofacial or back and spinal surgery.
- The Benefit payable against all anaesthetist costs is limited to a maximum of two times the Medical Scheme Rate on all Medical Aid Plans. This is irrespective of the service provider used.
- The Benefits payable against maxillofacial, back and spinal surgery and/or orthopaedic surgery, are limited to a maximum of one times the Medical Scheme Rate on all Medical Aid Plans. This is irrespective of the service provider used.
- Co-payments and Deductibles
- Includes MRI, CT and PET scans if it occurs during a covered event.
- Limited to certain diagnostic and medical procedures and treatment.
- Shortfalls from Sub-limits
- Up to a maximum compensation limit of R50 000 per beneficiary, per event.
- Penalty Co-payment
- Up to a maximum compensation limit of R15 000 per one event, per family, per annum.
- Dental Benefit
- Up to a maximum compensation limit of R5 000 for tariff shortfall and R5 000 for co-payment per policy, per annum (limited to two events per policy, per annum) for limited basic and specialised dentistry as defined in the policy document.
Childbirth Benefit
Up to a maximum of two times the Medical Scheme rate, based on the family member's Medical Aid Plan and subject to a maximum compensation limit of R15 000 per hospital event.
MAXIMUM COMPENSATION FOR ALL GAP COVER BENEFITS*
The total maximum Compensation Limit payable for all Core Benefits and Benefit Extender will be limited to R204 500 (two hundred and four thousand and five hundred rand) per family member, per annum.
- Includes cover for principal member and six dependants.
* Cover benefits, limits and maximum compensation limit applicable from 1 January 2024.
Terms & Conditions apply.
IMPORTANT TO NOTE:
- During the first 12 months of membership, a pre-existing condition waiting period applies.
- During the first 3 months of membership, a general waiting period applies.
- During the first 12 months of membership, a pregnancy waiting period applies.
Please note the 3 months general waiting period, 12 months pre-existing condition waiting period and 12 months pregnancy waiting period apply to an insured person from the time that such person's cover commences under the policy (to run concurrently if two or more waiting periods are applicable to an insured family member).
