| Benefits |
% Cost |
Limit |
| Overall Core Benefit Limit |
|
R750 000 per family per annum |
| Hospitals & Day Clinics * Pre-authorisation
required, call 0860 PROTEA |
| Private Hospitals |
100% of NRPL |
R100 000 Per Beneficiary Per Annum |
Public Hospitals
|
100% of Cost |
Subject to Overall Limit |
| Ward fees – General; ICU; High Care |
100% |
|
| Theatre Fees, Medication (only whilst in hospital) |
100% |
|
| Surgical Prostheses – e.g. artificial joints, artificial
limbs, pacemakers |
100% |
R10 000 Per Annum |
| Dialysis and Oncology |
100% |
Public Facilities Only (R60 000 Per Annum) |
| Clinical Technologist |
100% |
|
| Confinements |
|
|
| Normal Birth |
100% |
3 Days |
| Caesarian Section |
100% |
4 Days |
| Psychiatric Treatment |
100% |
7 Days per person per annum |
| Hospice and Private Nursing in Lieu of Hospitalisation |
100% |
R5 000 per family per annum |
| Maxillo-Facial Surgery - injury cases only |
100% |
|
| Ambulance Services |
|
International SOS for emergency transport only. Call toll
free 011 541 1118 |
| Dental Surgery |
- |
No Benefit |
| Medical Practitioners - In Hospital |
| General Practitioners & Specialists |
100% |
Subject to Hospital Limits above |
| Radiology & Pathology |
100% |
Subject to Hospital Limits above |
| MRI & CAT Scans – injury cases only |
100% |
Subject to Hospital Limits above |
| Statuatory Prescribed Minimum Benifits |
100% of Cost |
For services rendered by Public Hospitals paid in terms
of the PMB criteria at contracted rates. |
| Ambulatory Services |
| General Practitioner Visits, In
Rooms Procedures, Materials and Injections from the Selected
Doctor Only |
100 % |
Unlimited from selected doctor |
| Acute Medication (In terms of Formulary from
Selected Doctor Only) |
100 % |
Unlimited from selected doctor |
| Approved Chronic Medication (In terms of Formulary
from Selected Doctor Only) |
100 % |
Unlimited from selected doctor |
| Radiology * (Black and While Xrays Only) |
100 % |
On referral from Selected Doctor |
| Pathology * (Routine Blood and Urine Tests only) |
100 % |
On referral from Selected Doctor |
| Emergency and after hour services |
100% |
R500 per family per annum |
| Other Services - Overall Annual Limit
R3000 per Family for services listed below |
Specialists *
(Call 0860 PROTEA for authorisation) |
100 % |
R1500 per family per annum |
| Optical
Eye Tests
Spectacles
Contact Lenses |
100 % of NRPL |
R750 per person |
| Dental
Conservative Dentistry
Specialised Dentistry |
100 % of NRPL
100 % of NRPL |
R2000 per family per annum |
Auxiliary Practitioners
Speech Therapy
Occupational Therapy |
100% of NRPL |
R 1500 per family per annum |
Pre-authorisation *
All items marked with an asterix above require pre-authorisation.
Please call 0860 PROTEA |
