| CORE HOSPITAL BENEFITS |
| Benefits |
% Cover
|
Limit |
| Statutory Prescribed Minimum Benefits |
100% of Cost |
For services rendered by Public Hospitals unless
involuntarily obtained elsewhere, paid in terms of PMB criteria. |
Hospital & Day Clinic Admissions -
includes all costs
|
R75,000 total cost per event
at 100% of Scheme Tariff |
Pre-Authorisation Required - phone 0860 776
832 |
Medical Practitioners, Radiology,
Pathology
|
100% of Scheme Tariff |
Subject to limit of R75,000 per Hospital event |
| PET, MRI & CT Scans |
100% of Scheme Tariff |
Co-Payment of 50% of cost, subject to limit
of R75,000 per Hospital event and/or PMBs |
| Oncology Treatment |
100%
of Scheme Tariff |
R100,000 per beneficiary per annum, subject
to SAOC level 1 protocols and PMBs |
| Renal Failure & Kidney Dialysis |
100%
of Scheme Tariff |
R100,000 per family per annum, subject to PMBs & State
Criteria |
Prostheses, Medical & Surgical
Appliances
|
100% of Cost |
R20,000 per family per annum, subject to PMBs |
| Dental Surgery |
100%
of Scheme Tariff |
R2,500 per beneficiary per annum |
Private Nursing, including Step-down & Rehabilitation
Facilities
|
100%
of Scheme Tariff |
R8,500 per family per annum, in lieu of hospitalisation.
No Frail Care. |
| Confinement |
100%
of Scheme Tariff |
2 days per confinement, 3days for Caesarian delivery, subject
to limit of R75,000per Hospital event |
Psychiatric Hospitalisation, including
Practitioners
|
100%
of Scheme Tariff |
Maximum of 14 days, subjec |
| Alcoholism & Drug Dependence |
100%
of Cost |
PMBs only |
| Ambulance Services |
100%
of Scheme Tariff |
Emergency transportation only with pre-authorisation obtained
from 011-5411118 |
| CHRONIC CONDITIONS |
Chronic Conditions in terms of the
Regulations of the Medical Schemes Act, 131 of 1998, being
-
Addison’s Disease
Asthma
Bipolar Mood Disorder
Bronchiectasis
Cardiac Failure
Cardiomyopathy
Chronic Renal Disease
Chronic Obstructive Pulmonary Disease
Coronary Artery Disease
Crohns Disease
Diabetes Insipidus
Diabetes Mellitus Type 1 & 2
Dysrrhythmias
Epilepsy
Glaucoma
Haemophilia
Hyperlipidaemia
Hypertension
Multiple Sclerosis
Parkinsons Disease
Rheumatoid Arthritis
Schizophrenia
Systemic Lupus Erythematosus |
100%
of Cost |
Limited to the prescribed Therapeutic
Algorithms for the conditions and protocols in terms of best
practice adopted by the Scheme. Registration with the Scheme
is compulsory prior to receiving benefits. |
