CORPORATE ESSENTIAL
DAY-TO-DAY BENEFIT OPTION
WHO’S COVERED?
We cover 2 or more employees as an employer group if you join through your employer. Ask us for a quote.
Premiums are determined by factors such as the size of the employer group, the average age, and whether cover is compulsory or voluntary.
If your employer agrees to your spouse and dependants joining, add them to your policy.
We’ll cover you, your spouse, and any child dependant of whom you are the parent or legal guardian.
Child dependant premiums apply to children 20 or younger, and adult dependant premiums to children between 21 and 25.
From age 26, child dependants don’t qualify for cover under the same policy.
Your and your spouse’s parents may join as adult dependants. Adult dependant premiums will apply.
Other extended family members don’t qualify for cover.
ASK US FOR A CORPORATE QUOTE!
CLICK THE IMAGE BELOW TO VIEW OR
DOWNLOAD OUR BROCHURE.
Through a national network of providers who have contracted with Unity Health, our health insurance administrator, you can access more than 4 100 GPs and various optometry, pharmacy, pathology and radiology providers.
Download the Unity Health mobile app to find your nearest providers.
Click here for a guide on how to download the app and the useful features it offers.
CONSULTATION COVER
GP CONSULTATIONS AND MEDICAL PROCEDURES
You can visit any network GP as many times as needed.
Basic medical and surgical procedures can be performed in the doctor’s room based on a list of approved procedures, such as stitching a wound, circumcision and applying a cast to a broken arm.
Pre-authorisation for each network GP consultation is required.
GP PRE-AUTH WAIVER
Add the GP PRE-AUTH WAIVER for a additional premium per policy per month to see your network GP without prior approval.
Good to know: If you don’t add this benefit when you join, you can do so for the next benefit year beginning 1 January 2026.
HOW TO OBTAIN PRE-AUTHORISATION:
• Send a free “Please Call Me” by texting “UH please call” to 30947; or
• Access UCare, a symptom assessment tool available in the Unity Health mobile app or online portal; or
• Call us on 011 781 4488
OUT-OF-NETWORK GP CONSULTATIONS
Visit any out-of-network GP when you can’t get to your network GP.
You’ll be refunded up to R 330 per consultation, limited to 2 consultations per person per year.
Partners in Telemedicine:
INTERCARE ONLINE GP CONSULTATIONS
You may have a virtual GP consultations with an Intercare healthcare provider as often as needed.
Access this benefit in the Unity Health mobile app or online portal.
TELEMEDICINE GP CONSULTATIONS
Virtual GP consultations can be arranged during one of your nurse consultations. The nurse will determine if it’s necessary to consult with a GP and help set up a virtual consultation through a video conference link.
Virtual GP consultations at Alpha Pharm, Clicks, Dis-Chem or The Local Choice pharmacy clinics are unlimited.
Download the Unity Health mobile app to find your nearest approved pharmacy with a nurse clinic that is partnered with AlphaDoc, Healthforce, or Udok.
NURSE CONSULTATIONS
The nurse at your nearest Alpha Pharm, Clicks, Dis-Chem or The Local Choice pharmacy clinic can treat minor ailments and provide up to Schedule 2 medication.
There’s no limit to the number of times you may see a nurse. If the nurse recommends a virtual GP consultation during your consultation, the nurse will facilitate it. Refer to the TELEMEDICINE GP CONSULTATION BENEFIT.
Acute medication is subject to the approved medicine formulary and has no benefit limit.
SPECIALIST CONSULTATIONS
When the medical treatment provided by your network GP fails, and you need more specialised care, your GP must refer you, and the specialist consultation must be pre-authorised.
You’ll be refunded up to R 1 600 per consultation, limited to R 3 350 per family per year. This benefit will be pro-rated depending on your cover start date.
If the specialist refers you for blood tests and x-rays that are on the list of approved codes, the cost will be covered by the BLOOD TESTS AND X-RAYS BENEFIT or the SPECIALIST CONSULTATION BENEFIT if it’s not on the list.
The ACUTE MEDICATION BENEFIT covers medication the specialist prescribes if it’s on the approved formulary or the SPECIALIST CONSULTATION BENEFIT if it’s not on the formulary.
PRE-BIRTH CONSULTATIONS
Soon-to-be moms can visit any gynaecologist of their choice for check-ups and scans before the delivery.
You’ll be refunded for 3 consultations and 3 ultrasound scans (2D), limited to R 4 000 per family per year.
Pre-authorisation is required before you see the gynaecologist.
This benefit covers the cost of consultations and ultrasound scans before the delivery, not any costs related to childbirth.
MEDICINE COVER
Partners in Medicine:
ACUTE MEDICATION
DISPENSING NETWORK GP
Acute medication that your network GP gives to you in the room from the approved Mediscor formulary has no benefit limit.
NON-DISPENSING NETWORK GP
If your network GP isn’t a dispensing doctor, you’ll be given a prescription to collect the medication at a network pharmacy.
Acute medication that your network GP prescribes from the approved Mediscor formulary has no benefit limit.
APPROVED MEDICINE FORMULARY
The medication your network GP, the nurse or the specialist prescribes or the medication that may be prescribed during a virtual GP or Intercare virtual GP consultation will be covered if it’s on the approved Mediscor formulary.
Mediscor is a pharmaceutical benefits management organisation.
A formulary is an approved list of medicines Unity Health covers in full.
Sometimes, non-formulary medicines may be prescribed if it’s best for your health. When this happens, and there’s no generic on the formulary, the cost will be for your pocket.
CHRONIC MEDICATION
You’re covered for chronic medication that your network GP prescribes from the approved Mediscor formulary for the following chronic conditions or diseases:
- Addison’s disease;
- asthma;
- bi-polar mood disorder;
- bronchiectasis;
- cardiac failure;
- cardiomyopathy disease;
- chronic renal disease;
- coronary artery disease;
- Crohn’s disease;
- chronic obstructive pulmonary disorder;
- diabetes insipidus;
- diabetes type 1 & 2;
- dysrhythmia;
- epilepsy;
- glaucoma;
- HIV/AIDS;
- haemophilia;
- hypertension;
- hyperlipidaemia;
- hypothyroidism;
- multiple sclerosis;
- Parkinson’s disease;
- rheumatoid arthritis;
- schizophrenia;
- systemic lupus erythematosus;
- tuberculosis; and
- ulcerative colitis.
Your network GP can help register you on the Chronic Medication Programme with Mediscor.
Once you’re registered to receive chronic medication, your medication can be delivered, or you can collect it at your nearest network pharmacy.
Click here to view or download a Chronic Medication Benefit Guide.
BLOODS, X-RAYS, DENTAL AND EYE CARE COVER
BLOOD TESTS AND X-RAYS
When you need a blood test, such as a cholesterol or glucose test, your network GP will refer you to the nearest Ampath, Lancet or PathCare pathology facility.
You’re also covered for a Covid-19 PCR screening test if your network GP refers you, pre-authorisation is obtained and if you test positive for Covid-19. Limited to 1 test per person per year.
Basic black-and-white x-rays, such as a chest x-ray, are covered when your network GP refers you to a radiology facility during one of your visits.
Blood tests and x-rays on the list of approved codes are unlimited, but specific diagnostic blood tests are limited if the tests aren’t part of an approved chronic disease treatment plan.
Specialised radiology, such as MRI and CT scans, aren’t covered.
DENTAL CARE
Visit any dentist for basic dental treatment.
This benefit covers full mouth assessments, intraoral radiographs, scaling and polishing, extractions, emergency root canal treatments, fillings, and pain and sepsis treatments according to a list of
approved codes and agreed rates.
Limited to:
• Single member: R 1 500 per policy per year
• Member + 1: R 1 500 per person, limited to R 3 000 per family per year
• Member + 2 or more: R 1 500 per person, limited to R 4 500 per family per year
This benefit will be prorated depending on your cover start date.
Find a recommended dentist on the Unity Health mobile app.
Partners in Optometry:
EYE CARE
Unity Health has an exclusive network arrangement with Specsavers and Execuspecs.
Visit your nearest network optometrist for:
• 1 eye test per person every 2 years;
• 1 standard frame to the value of R 599 per person every 2 years; and
• 1 pair of clear, standard spectacle lenses per person every 2 years.
Specsavers and Execuspecs are part of the Preferred Provider Network (PPN), the largest optical network in the country.
To find your nearest Specsavers or Execuspecs optometrist, visit www.ppn.co.za or search in the Unity Health mobile app.
Optional extras, like tinting or scratch resistant coatings, aren’t covered.
WELLNESS BENEFITS
WELLNESS ASSESSMENT
As an employee of a registered employer group, you’re covered for 1 wellness assessment per person per year for the following on-site basic health checks when an Employee Wellness Day is scheduled for 15 or more employees:
- blood pressure;
- body mass index;
- cholesterol;
- glucose levels;
- waist circumference; and
- HIV/AIDS, that includes counselling before and after testing.
Additional health checks can be done during the Wellness Day:
• breast screening using a BreastlightTM device for all female employees;
• eye test;
• prostate screening every 2 years for male employees aged 50 years or older; and
• tuberculosis rapid test for all high-risk employees.
If you miss the Wellness Day, you may visit your nearest Alpha Pharm, Clicks, Dis-Chem, or The Local Choice pharmacy clinic to have your basic health checks and prostate screening done.
Your dependants may have their basic health checks and prostate screening done at their nearest Alpha Pharm, Clicks, Dis-Chem, or The Local Choice pharmacy clinic.
PREVENTATIVE CARE
Alpha Pharm, Clicks, Dis-Chem and The Local Choice pharmacy clinics are approved network providers for your preventative tests and vaccinations.
You have access to the following vaccinations and preventative tests:
VACCINATIONS
• 1 flu vaccination per person per year to be administered by the 31st of May;
• 1 pneumococcal vaccination every 5 years for individuals 60 years or older, or for individuals with a medically proven compromised immune system;
(Pre-authorisation for a pneumococcal vaccination is required.)
• 1 hepatitis A and B vaccination once-off per person; and
• 1 tetanus vaccination per person every 10 years.
TESTS AND SCREENINGS
• 1 pap smear every 3 years for females aged 21 years or older
(Ask your network GP about having a pap smear done in the room during one of your consultations); or
• 1 prostate screening every 2 years for males aged 50 years or older.
(PSA pathology tests aren’t covered)
ESSENTIAL ASSISTANCE PROGRAMME (EAP)
Get telephonic advice and counselling services through Reality Wellness Group.
These services give you and your registered dependants virtual or telephonic counselling support by registered counsellors who follow clinical protocols and specific procedures.
Includes support for:
- financial advice;
- legal advice;
- HIV/AIDS counselling and case management; and
- trauma counselling.
Download the Reality Wellness Group mobile app from your app store to access holistic wellness services.
Virtual counselling sessions can be arranged but face-to-face counselling isn’t covered.
OPEN ENROLMENT, COMMUNITY RATING AND CROSS-SUBSIDISATION
Health insurance policies are subject to open enrolment, community rating and cross-subsidisation. This means that cover is available to everyone, there’s no discrimination based on factors like race and gender, and all premiums received are paid into one risk pool from where claims are paid.
This policy isn’t a medical aid plan, doesn’t provide similar cover as that of a medical aid, and can’t be substituted for a medical aid membership.
WAITING PERIODS AND GENERAL EXCLUSIONS
WAITING PERIODS
Waiting periods don’t apply to employer groups when it’s compulsory for 20 or more employees to join.
When fewer than 20 employees join, or when it’s voluntary for employees to join, the following waiting periods apply:
GENERAL WAITING PERIOD
1 MONTH GENERAL WAITING PERIOD applies if the GP PRE-AUTH WAIVER is added.
0 MONTH GENERAL WAITING PERIOD applies if the GP PRE-AUTH WAIVER isn’t added.
There’s no cover during this period for the DAY-TO-DAY BENEFITS, WELLNESS ASSESSMENT and PREVENTATIVE CARE BENEFITS.
9 MONTH PRE-BIRTH CONSULTATION WAITING PERIOD
12 MONTH CHRONIC MEDICATION WAITING PERIOD
12 MONTH EYE CARE WAITING PERIOD
EXCEPTION TO THE RULE
Waiting periods don’t apply to the ESSENTIAL ASSISTANCE PROGRAMME (EAP).
GENERAL EXCLUSIONS
The Company isn’t liable for bodily injury, disease, hospitalisation, medical treatment, or sickness directly or indirectly caused by, related to or in consequence of:
1. medical events that occurred before your cover start date.
2. medical events during waiting periods, except for accidents and emergencies, where applicable.
3. medical events when benefit limits have been reached.
4. medical events your policy doesn’t cover or provide an appropriate benefit to claim from.
5. medical events for which pre-authorisation or a healthcare provider referral hasn’t been obtained, where applicable.
6. more than one general practitioner, nurse, or virtual general practitioner consultation on the same day for the same insured person.
7. medical events when using healthcare or service providers not part of the provider network, except if your policy offers a benefit.
8. healthcare services, procedures, or medication not part of the list of approved tariff codes or formularies, where applicable.
9. allied healthcare providers’ consultations, such as physiotherapists and speech therapists, under the Specialist Consultation Benefit.
10. eye care, except an eye test, frame and spectacle lenses under the Eye Care Benefit.
11. costs that, in the opinion of the Underwriting Manager’s clinical review team:
a. aren’t medically necessary or clinically appropriate;
b. don’t meet the healthcare needs of the insured person; or
c. aren’t consistent in type, frequency, or duration of treatment.
12. failure to follow medical advice or adherence to treatment as prescribed.
13. cosmetic surgery or surgery directly or indirectly caused by, related to or in consequence of cosmetic surgery.
14. investigations, treatment, surgery for obesity, or any medical treatment directly or indirectly caused by or related to any condition that is a consequence of a claimable event.
15. external prosthetic devices or medical items, such as artificial limbs and wheelchairs.
16. artificial insemination, infertility treatment or contraceptives.
17. robotic surgery, specialised mechanical or computerised appliances, or equipment.
18. routine physical procedures of a purely diagnostic nature or examinations with no objective indication of impairment in normal health, including laboratory, diagnostic or x-ray examinations, except during a medical condition or disability
established by a prior call or attendance of a medical practitioner.
19. participation or any act or activity which is calculated or directed to bring about riots, wars, war-like operations (whether war be declared or not), invasions, acts of foreign enemies, hostilities, public disorder, terrorism, civil commotions,
civil wars, labour disturbances, strikes, activities of locked-out workers.
20. mutiny, military rising, military or usurped power, martial law or state of siege, or any other event or cause which determines the proclamation or maintenance of martial law or state of siege, insurrection, rebellion or revolution.
21. any cost, damage, expense, liability, or loss which results or arises from or is contributed by any other cause or event that contributes concurrently or in sequence to the loss, damage, expense, liability, or loss where that other cause or event isn’t expressly insured, or is expressly excluded under this policy.
22. any act which is calculated or directed to bring about loss or damage to further any political aim, objective or cause, or to bring about any social or economic change, or in protest against any state or government or any provincial, local or
tribal authority, or for the purpose of inspiring fear in the public or any section thereof.
23. deliberate criminal or fraudulent acts, or any illegal activity conducted by you or a member of your household which directly or indirectly results in loss, damage or injury.
24. attempted suicide, suicide, intentional self-injury, or deliberate exposure to exceptional danger, except if trying to save a human life.
25. events where the use of drugs, narcotics or alcohol are involved, including any illness or addiction caused by using such substances.
26. participation in:
a. active military, police or police reservist duty;
b. aviation, other than as a passenger;
c. any competitive or professional sport or activity; or
d. any race or speed test, except on foot or involving any non-mechanically propelled vehicle, vessel, craft or aircraft.
27. nuclear weapons, nuclear material, ionising radiation, contamination by radioactivity from any nuclear fuel or nuclear waste, or from the combustion of nuclear fuel, including any self-sustaining process of nuclear fission.
28. events that occur for which the actual damage is provided for by legislation, including contractual liability and consequential loss.
29. non-disclosure of material information that is likely to affect the assessment or acceptance of risk.
30. dual insurance where cover is provided by more than one health insurance policy through different insurers, or the same insurer.
31. the failure of any electricity grid. This is applicable to any loss, damage, cost, expense or liability of whatsoever nature.
CORPORATE ESSENTIAL
DAY-TO-DAY BENEFIT OPTION
This health insurance option, in partnership with Unity Health, offers comprehensive and essential day-to-day cover through a national network of private healthcare providers.
WHO’S COVERED?
We cover 2 or more employees as an employer group if you join through your employer. Ask us for a quote.
Premiums are determined by factors such as the size of the employer group, the average age, and whether cover is compulsory or voluntary.
If your employer agrees to your spouse and dependants joining, add them to your policy.
We’ll cover you, your spouse, and any child dependant of whom you are the parent or legal guardian.
Child dependant premiums apply to children 20 or younger, and adult dependant premiums to children between 21 and 25.
From age 26, child dependants don’t qualify for cover under the same policy.
Your and your spouse’s parents may join as adult dependants. Adult dependant premiums will apply.
Other extended family members don’t qualify for cover.
ASK US FOR A CORPORATE QUOTE!
Through a national network of providers who have contracted with Unity Health, our health insurance administrator, you can access more than 4 100 GPs and various optometry, pharmacy, pathology and radiology providers.
Download the Unity Health mobile app to find your nearest providers.
Click here for a guide on how to download the app and the useful features it offers.
CONSULTATION COVER
GP CONSULTATIONS AND MEDICAL PROCEDURES
You can visit any network GP as many times as needed.
Basic medical and surgical procedures can be performed in the doctor’s room based on a list of approved procedures, such as stitching a wound, circumcision and applying a cast to a broken arm.
Pre-authorisation for each network GP consultation is required.
GP PRE-AUTH WAIVER
Add the GP PRE-AUTH WAIVER for a additional premium per policy per month to see your network GP without prior approval.
Good to know: If you don’t add this benefit when you join, you can do so for the next benefit year beginning 1 January 2026.
HOW TO OBTAIN PRE-AUTHORISATION:
• Send a free “Please Call Me” by texting “UH please call” to 30947; or
• Access UCare, a symptom assessment tool available in the Unity Health mobile app or online portal; or
• Call us on 011 781 4488
OUT-OF-NETWORK GP CONSULTATIONS
Visit any out-of-network GP when you can’t get to your network GP.
You’ll be refunded up to R 330 per consultation, limited to 2 consultations per person per year.
INTERCARE ONLINE GP CONSULTATIONS
You may have a virtual GP consultations with an Intercare healthcare provider as often as needed.
Access this benefit in the Unity Health mobile app or online portal.
TELEMEDICINE GP CONSULTATIONS
Virtual GP consultations can be arranged during one of your nurse consultations. The nurse will determine if it’s necessary to consult with a GP and help set up a virtual consultation through a video conference link.
Virtual GP consultations at an Alpha Pharm, Dis-Chem, or The Local Choice pharmacy clinics are unlimited.
Download the Unity Health mobile app to find your nearest approved pharmacy with a nurse clinic that is partnered with AlphaDoc, Healthforce, or Udok.
Partners in Telemedicine:
NURSE CONSULTATIONS
The nurse at your nearest Alpha Pharm, Clicks, Dis-Chem or The Local Choice pharmacy clinic can treat minor ailments and provide up to Schedule 2 medication.
There’s no limit to the number of times you may see a nurse. If the nurse recommends a virtual GP consultation during your consultation, the nurse will facilitate it. Refer to the TELEMEDICINE GP CONSULTATION BENEFIT.
Acute medication is subject to the approved medicine formulary and has no benefit limit.
SPECIALIST CONSULTATIONS
When the medical treatment provided by your network GP fails, and you need more specialised care, your GP must refer you, and the specialist consultation must be pre-authorised.
You’ll be refunded up to R 1 600 per consultation, limited to R 3 350 per family per year. This benefit will be pro-rated depending on your cover start date.
If the specialist refers you for blood tests and x-rays that are on the list of approved codes, the cost will be covered by the BLOOD TESTS AND X-RAYS BENEFIT or the SPECIALIST CONSULTATION BENEFIT if it’s not on the list.
The ACUTE MEDICATION BENEFIT covers medication the specialist prescribes if it’s on the approved formulary or the SPECIALIST CONSULTATION BENEFIT if it’s not on the formulary.
PRE-BIRTH CONSULTATIONS
Soon-to-be moms can visit any gynaecologist of their choice for check-ups and scans before the delivery.
You’ll be refunded for 3 consultations and 3 ultrasound scans (2D), limited to R 4 000 per family per year.
Pre-authorisation is required before you see the gynaecologist.
This benefit covers the cost of consultations and ultrasound scans before the delivery, not any costs related to childbirth.
MEDICINE COVER
ACUTE MEDICATION
DISPENSING NETWORK GP
Acute medication that your network GP gives to you in the room from the approved Mediscor formulary has no benefit limit.
NON-DISPENSING NETWORK GP
If your network GP isn’t a dispensing doctor, you’ll be given a prescription to collect the medication at a network pharmacy.
Acute medication that your network GP prescribes from the approved Mediscor formulary has no benefit limit.
APPROVED MEDICINE FORMULARY
The medication your network GP, the nurse or the specialist prescribes or the medication that may be prescribed during a virtual GP or Intercare virtual GP consultation will be covered if it’s on the approved Mediscor formulary.
Mediscor is a pharmaceutical benefits management organisation.
A formulary is an approved list of medicines Unity Health covers in full.
Sometimes, non-formulary medicines may be prescribed if it’s best for your health. When this happens, and there’s no generic on the formulary, the cost will be for your pocket.
Partners in Medicine:
CHRONIC MEDICATION
You’re covered for chronic medication that your network GP prescribes from the approved Mediscor formulary for the following chronic conditions or diseases:
- Addison’s disease;
- asthma;
- bi-polar mood disorder;
- bronchiectasis;
- cardiac failure;
- cardiomyopathy disease;
- chronic renal disease;
- coronary artery disease;
- Crohn’s disease;
- chronic obstructive pulmonary disorder;
- diabetes insipidus;
- diabetes type 1 & 2;
- dysrhythmia;
- epilepsy;
- glaucoma;
- HIV/AIDS;
- haemophilia;
- hypertension;
- hyperlipidaemia;
- hypothyroidism;
- multiple sclerosis;
- Parkinson’s disease;
- rheumatoid arthritis;
- schizophrenia;
- systemic lupus erythematosus;
- tuberculosis; and
- ulcerative colitis.
Your network GP can help register you on the Chronic Medication Programme with Mediscor.
Once you’re registered to receive chronic medication, your medication can be delivered, or you can collect it at your nearest network pharmacy.
Click here to view or download a Chronic Medication Benefit Guide.
BLOODS, X-RAYS, DENTAL AND
EYE CARE COVER
BLOOD TESTS AND X-RAYS
When you need a blood test, such as a cholesterol or glucose test, your network GP will refer you to the nearest Ampath, Lancet or PathCare pathology facility.
You’re also covered for a Covid-19 PCR screening test if your network GP refers you, pre-authorisation is obtained and if you test positive for Covid-19. Limited to 1 test per person per year.
Basic black-and-white x-rays, such as a chest x-ray, are covered when your network GP refers you to a radiology facility during one of your visits.
Blood tests and x-rays on the list of approved codes are unlimited, but specific diagnostic blood tests are limited if the tests aren’t part of an approved chronic disease treatment plan.
Specialised radiology, such as MRI and CT scans, aren’t covered.
DENTAL CARE
Visit any dentist for basic dental treatment.
This benefit covers full mouth assessments, intraoral radiographs, scaling and polishing, extractions, emergency root canal treatments, fillings, and pain and sepsis treatments according to a list of
approved codes and agreed rates.
Limited to:
• Single member: R 1 500 per policy per year
• Member + 1: R 1 500 per person, limited to R 3 000 per family per year
• Member + 2 or more: R 1 500 per person, limited to R 4 500 per family per year
This benefit will be prorated depending on your cover start date.
Find a recommended dentist on the Unity Health mobile app.
EYE CARE
Unity Health has an exclusive network arrangement with Specsavers and Execuspecs.
Visit your nearest network optometrist for:
• 1 eye test per person every 2 years;
• 1 standard frame to the value of R 599 per person every 2 years; and
• 1 pair of clear, standard spectacle lenses per person every 2 years.
To find your nearest Specsavers or Execuspecs optometrist, visit www.ppn.co.za or search in the Unity Health mobile app.
Optional extras, like tinting or scratch resistant coatings, aren’t covered.
Partners in Optometry:
WELLNESS BENEFITS
WELLNESS ASSESSMENT
As an employee of a registered employer group, you’re covered for 1 wellness assessment per person per year for the following on-site basic health checks when an Employee Wellness Day is scheduled for 15 or more employees:
- blood pressure;
- body mass index;
- cholesterol;
- glucose levels;
- waist circumference; and
- HIV/AIDS, that includes counselling before and after testing.
Additional health checks can be done during the Wellness Day:
• breast screening using a BreastlightTM device for all female employees;
• eye test;
• prostate screening every 2 years for male employees aged 50 years or older; and
• tuberculosis rapid test for all high-risk employees.
If you miss the Wellness Day, you may visit your nearest Alpha Pharm, Clicks, Dis-Chem, or The Local Choice pharmacy clinic to have your basic health checks and prostate screening done.
Your dependants may have their basic health checks and prostate screening done at their nearest Alpha Pharm, Clicks, Dis-Chem, or The Local Choice pharmacy clinic.
PREVENTATIVE CARE
Alpha Pharm, Clicks, Dis-Chem and The Local Choice pharmacy clinics are approved network providers for your preventative tests and vaccinations.
You have access to the following vaccinations and preventative tests:
VACCINATIONS
• 1 flu vaccination per person per year to be administered by the 31st of May;
• 1 pneumococcal vaccination every 5 years for individuals 60 years or older, or for individuals with a medically proven compromised immune system;
(Pre-authorisation for a pneumococcal vaccination is required.)
• 1 hepatitis A and B vaccination once-off per person; and
• 1 tetanus vaccination per person every 10 years.
TESTS AND SCREENINGS
• 1 pap smear every 3 years for females aged 21 years or older
(Ask your network GP about having a pap smear done in the room during one of your consultations); or
• 1 prostate screening every 2 years for males aged 50 years or older.
(PSA pathology tests aren’t covered)
ESSENTIAL ASSISTANCE PROGRAMME (EAP)
Get telephonic advice and counselling services through Reality Wellness Group.
These services give you and your registered dependants virtual or telephonic counselling support by registered counsellors who follow clinical protocols and specific procedures.
Includes support for:
- financial advice;
- legal advice;
- HIV/AIDS counselling and case management; and
- trauma counselling.
Download the Reality Wellness Group mobile app from your app store to access holistic wellness services.
Virtual counselling sessions can be arranged but face-to-face counselling isn’t covered.
OPEN ENROLMENT, COMMUNITY RATING AND CROSS-SUBSIDISATION
Health insurance policies are subject to open enrolment, community rating and cross-subsidisation. This means that cover is available to everyone, there’s no discrimination based on factors like race and gender, and all premiums received are paid into one risk pool from where claims are paid.
This policy isn’t a medical aid plan, doesn’t provide similar cover as that of a medical aid, and can’t be substituted for a medical aid membership.
WAITING PERIODS AND
GENERAL EXCLUSIONS
WAITING PERIODS
Waiting periods don’t apply to employer groups when it’s compulsory for 20 or more employees to join.
When fewer than 20 employees join, or when it’s voluntary for employees to join, the following waiting periods apply:
GENERAL WAITING PERIOD
1 MONTH GENERAL WAITING PERIOD applies if the GP PRE-AUTH WAIVER is added.
0 MONTH GENERAL WAITING PERIOD applies if the GP PRE-AUTH WAIVER isn’t added.
There’s no cover during this period for the DAY-TO-DAY BENEFITS, WELLNESS ASSESSMENT and PREVENTATIVE CARE BENEFITS.
9 MONTH PRE-BIRTH CONSULTATION WAITING PERIOD
12 MONTH CHRONIC MEDICATION WAITING PERIOD
12 MONTH EYE CARE WAITING PERIOD
EXCEPTION TO THE RULE
Waiting periods don’t apply to the ESSENTIAL ASSISTANCE PROGRAMME (EAP).
GENERAL EXCLUSIONS
The Company isn’t liable for bodily injury, disease, hospitalisation, medical treatment, or sickness directly or indirectly caused by, related to or in consequence of:
1. medical events that occurred before your cover start date.
2. medical events during waiting periods, except for accidents and emergencies, where applicable.
3. medical events when benefit limits have been reached.
4. medical events your policy doesn’t cover or provide an appropriate benefit to claim from.
5. medical events for which pre-authorisation or a healthcare provider referral hasn’t been obtained, where applicable.
6. more than one general practitioner, nurse, or virtual general practitioner consultation on the same day for the same insured person.
7. medical events when using healthcare or service providers not part of the provider network, except if your policy offers a benefit.
8. healthcare services, procedures, or medication not part of the list of approved tariff codes or formularies, where applicable.
9. allied healthcare providers’ consultations, such as physiotherapists and speech therapists, under the Specialist Consultation Benefit.
10. eye care, except an eye test, frame and spectacle lenses under the Eye Care Benefit.
11. costs that, in the opinion of the Underwriting Manager’s clinical review team:
a. aren’t medically necessary or clinically appropriate;
b. don’t meet the healthcare needs of the insured person; or
c. aren’t consistent in type, frequency, or duration of treatment.
12. failure to follow medical advice or adherence to treatment as prescribed.
13. cosmetic surgery or surgery directly or indirectly caused by, related to or in consequence of cosmetic surgery.
14. investigations, treatment, surgery for obesity, or any medical treatment directly or indirectly caused by or related to any condition that is a consequence of a claimable event.
15. external prosthetic devices or medical items, such as artificial limbs and wheelchairs.
16. artificial insemination, infertility treatment or contraceptives.
17. robotic surgery, specialised mechanical or computerised appliances, or equipment.
18. routine physical procedures of a purely diagnostic nature or examinations with no objective indication of impairment in normal health, including laboratory, diagnostic or x-ray examinations, except during a medical condition or disability
established by a prior call or attendance of a medical practitioner.
19. participation or any act or activity which is calculated or directed to bring about riots, wars, war-like operations (whether war be declared or not), invasions, acts of foreign enemies, hostilities, public disorder, terrorism, civil commotions,
civil wars, labour disturbances, strikes, activities of locked-out workers.
20. mutiny, military rising, military or usurped power, martial law or state of siege, or any other event or cause which determines the proclamation or maintenance of martial law or state of siege, insurrection, rebellion or revolution.
21. any cost, damage, expense, liability, or loss which results or arises from or is contributed by any other cause or event that contributes concurrently or in sequence to the loss, damage, expense, liability, or loss where that other cause or event isn’t expressly insured, or is expressly excluded under this policy.
22. any act which is calculated or directed to bring about loss or damage to further any political aim, objective or cause, or to bring about any social or economic change, or in protest against any state or government or any provincial, local or
tribal authority, or for the purpose of inspiring fear in the public or any section thereof.
23. deliberate criminal or fraudulent acts, or any illegal activity conducted by you or a member of your household which directly or indirectly results in loss, damage or injury.
24. attempted suicide, suicide, intentional self-injury, or deliberate exposure to exceptional danger, except if trying to save a human life.
25. events where the use of drugs, narcotics or alcohol are involved, including any illness or addiction caused by using such substances.
26. participation in:
a. active military, police or police reservist duty;
b. aviation, other than as a passenger;
c. any competitive or professional sport or activity; or
d. any race or speed test, except on foot or involving any non-mechanically propelled vehicle, vessel, craft or aircraft.
27. nuclear weapons, nuclear material, ionising radiation, contamination by radioactivity from any nuclear fuel or nuclear waste, or from the combustion of nuclear fuel, including any self-sustaining process of nuclear fission.
28. events that occur for which the actual damage is provided for by legislation, including contractual liability and consequential loss.
29. non-disclosure of material information that is likely to affect the assessment or acceptance of risk.
30. dual insurance where cover is provided by more than one health insurance policy through different insurers, or the same insurer.
31. the failure of any electricity grid. This is applicable to any loss, damage, cost, expense or liability of whatsoever nature.