Comprehensive Option
Hospitalisation Benefits
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Benefits will be allocated pro rata for beneficiaries or members joining during the year.
You must obtain authorisation for any non-emergency hospital admission and related treatment by calling 0800 118 666.If you do not obtain authorisation at least two days before any non-emergency hospital admission or related treatment, penalties may be applied and benefits may be withheld.
- YOUR MAJOR MEDICAL EXPENSES BENEFIT
Your major medical expenses benefit consists out of three categories:
Procedures performed in hospital Certain procedures performed in doctors'rooms, hospital medical facilities or day clinics, but paid from your major medical expenses benefit Additional procedures that are not performed in or out of hospital, but paid from your major medical expenses benefit. - SPECIFIED TIME LIMITS FOR PRE-AUTHORISATION
- DESIGNATED SERVICE PROVIDERS (DSPs) - NETWORK SPECIALIST
- HOW TO OBTAIN HOSPITAL PRE-AUTHORISATION
IN-HOSPITAL BENEFITS
| Benefits | Description | |
|---|---|---|
| Ambulance services - Netcare 911 - 082 911 | 100% of the agreed tariff. Subject to authorisation by Netcare 911 within 72 hours of the transport occurring. Unauthorised use of an ambulance for non-emergency treatment will not be covered by the Fund. For authorisation, please call 082 911 | 100% of the agreed tariff |
| Hospitalisation - private, provincial or State hospitals |
Paid at 3x the WHFT for authorised admissions Authorisation: 0800 118 666 |
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| Ward accommodation |
Paid at general ward tariffs, subject to pre-authorisation Authorisation: 0800 118 666 |
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| Take-home medication (after discharge from hospital) |
Limited to 7 days |
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| GPs - including surgery, procedures and consultations |
Paid 3x the WHFT |
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| Specialists - including surgery, procedures and consultations |
Non-PMB claims will be Paid 3x the WHFT |
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| Radiology - (including MRIs, CT scans and radio isotope studies) |
Paid 3x the WHFT |
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| Pathology | Paid 3x the WHFT | |
| Organ transplants |
Subject to pre-authorisation, managed care protocols, PMBs and networks Where the recipient is a beneficiary of the Fund, services rendered to the donor and the transportation of the organ are included in this benefit Where the donor is a beneficiary of the Fund, but the recipient is not, the donor costs will not be covered by the Fund, since these costs should be covered by the recipient's medical scheme |
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| Hospitalisation, organ and patient preparation | Paid 3x the WHFT | |
| Immuno-suppressant drugs dispensed in hospital or dispensed by the hospital to take out for use after discharge | 100% of Cost | 100% of costs |
| Subsequent supplies of immunosuppressant drugs | 100% of Cost, subject to pre-authorisation | 100% of costs |
| Robotic-assisted laparoscopic prostatectomy |
Paid 3x the WHFT Subject to clinical motivation, pre-authorisation and managed care protocols Must be performed at an accredited hospital Limited to R157 200 per qualifying Beneficiary per year for hospital and equipment |
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| Blood transfusions, transportation of blood and blood products | Paid 3x the WHFT | |
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Auxiliary services in hospital:
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Paid 3x the WHFT for authorised admissions The service/procedure must be directly related to the authorised admission Post-operative auxiliary services may be approved and benefits granted on condition that these services are received within six weeks after the hospital admission Subject to clinical motivation, pre-authorisation and managed care protocols |
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| Psychiatric treatment in hospital or at a registered facility |
Subject to pre-authorisation and limited to 21 days per beneficiary per year 1 Psychiatric or Psychology consultation post admission within 6 weeks post discharge Authorisation: 0800 118 666 |
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| Maxillofacial treatment |
Paid 3x the WHFT, subject to pre-authorisation |
IN-DOCTORS' ROOMS, HOSPITAL MEDICAL FACILITIES OR DAY CLINICS
| Benefits | Description | |
|---|---|---|
| Certain procedures performed in doctors' rooms only | Paid 3x the WHFT Excludes general anaesthetic |
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| Hospitalisation is subject to approval of clinical motivation and managed care protocols |
Cone biopsy, cauterisation of warts, colposcopy, nasal polypectomy, nasal cautery, meibomian cyst excision, circumcision, drainage of superficial abscess, superficial foreign body removal and breast biopsy Authorisation: 0800 118 666 |
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| Oncology, radiotherapy and chemotherapy in and out of hospital - medication/chemicals, related radiology, including MRIs and CT scans and pathology |
Limited to PMBs Full clinical motivation and treatment plan is required from the treating specialist and in line with South African Oncology Consortium (SAOC) guidelines Limited to R500 000 per family per year Subject to pre-authorisation, registration on the Oncology Risk Management Programme and oncology management protocols Subject to pre-authorisation Call 0800 118 666 to register |
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Endoscopic examinations:
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Paid 3x the WHFT if performed in doctors' rooms/outpatient/medical or surgical facilities R2 680 co-payment applies if performed in hospital without an approved clinical indication and Fund approval |
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| These procedures can be performed in doctors' rooms, and in outpatient/medical/surgical facilities |
Anaesthetic costs related to these scopes are limited to local or regional anaesthetic |
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| If performed in hospital, it will attract a member co-payment |
General anaesthetic costs are not covered Pathology costs related to these procedures will be covered from major medical expenses |
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Ophthalmologist examinations:
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Paid at 3x the WHFT if performed in doctors' rooms/outpatient/medical or surgical facilities A co-payment of R2 680 will apply should any of these procedures be performed in hospital, without an approved clinical indication and Fund approval Anaesthetic costs related to these procedures will be limited to local or regional anaesthetic General anaesthetic costs are not covered Pathology costs related to these procedures will be covered from Major Medical Expenses. |
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| Basic dentistry procedures in hospital - removal of teeth and multiple fillings for children 7 years and younger |
Paid 3x the WHFT, subject to pre-authorisation The dentist will be paid from your available MSA |
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| Specialised dentistry procedures in and out of hospital - dental implants and removal of impacted wisdom teeth | Paid 3x the WHFT, subject to pre-authorisation and limited to R24 160 per beneficiary per year | |
| Refractive surgery |
Paid 3x the WHFT, subject to pre-authorisation LASIK surgery benefit subject to guidelines for refractive surgery required for medical reasons A motivation, including the refractive error, is required Subject to approval by medical advisor and based on refraction levels |
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| Peritoneal dialysis and haemodialysis |
Paid 3x the WHFT, subject to pre-authorisation and managed care protocols |
ADDITIONAL BENEFITS
PAID FROM MAJOR MEDICAL EXPENSES BENEFIT
| Benefits | Description |
|---|---|
| Private Nursing |
Paid 3x the WHFT and limited to R5 910 per beneficiary per month Subject to clinical motivation by GP or specialist |
| Internal prostheses Appliances placed in the body as an internal adjuvant during an operation |
Paid 3x the WHFT, subject to pre-authorisation and limited to R78 180 per beneficiary per year Authorisation: 0800 118 666 |
| External Appliances Hearing aids, hearing aid repairs, wheelchairs, CPAP machines, external fixators and colostomy kits |
Paid 3x the WHFT, subject to written motivation, which must be received 72 hours before the request for pre-authorisation. Subject to managed care protocols Limited to R81 870 per Beneficiary, every two years with the following sub-limits:
Authorisation: 0800 118 666 |
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Medical and surgical appliances - including nebulisers, crutches, blood pressure machines, glucometers, etc. |
Paid 3x the WHFT, subject to clinical motivation and approval Subject to available MSA where pre-authorisation is not obtained |