CORPORATE ESSENTIAL PLAN D

DAY-TO-DAY BENEFIT OPTION

 

Through a national network of providers who’ve contracted with Unity Health, our health insurance administrator, you have access to more than 3 000 GP’s, 2 700 optometrists and various pharmacies, pathologists, and radiologists.

To find your nearest provider, download the Unity Health mobile app from Google Play Store or the App Store, refer to the Stratum Benefits Health Insurance App Download Guide or contact us on 011 781 4488 for assistance.

Unity Health has contracted with the following pharmacies:

CORPORATE ESSENTIAL

DAY-TO-DAY BENEFIT OPTION

 

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.

PREMIUMS FOR EMPLOYER GROUPS

ENTRY AGE INDIVIDUAL OR FAMILY
All ages R 324 per policy per month

Employer groups are covered if 2 or more employees join through their employer.
Ask your employer if your spouse and dependants may also join.

Joining as a family? This health insurance benefit option covers you, your spouse, and any child dependant as long as you’re their parent or legal guardian.

Premiums for children who are 20 years or younger are included in the policy premium.

Premiums for children who are 21 years or older are included in the policy premium and may be added to your policy if they’re full-time students, or if they’re financially dependent on you and proof is submitted every year.

What proof can be submitted? Proof from the educational facility, or stamped copies of your child’s bank account statements of the past 3 months together with an affidavit.

CONSULTATION COVER

GP CONSULTATIONS AND MEDICAL PROCEDURES

You can visit any network GP.
Basic medical and surgical procedures can be performed in the rooms, like stitching of a wound or applying a cast to a broken arm, as long as it’s on the approved list of tariff codes.
GP, nurse and virtual GP consultations have a combined limit of 5 consultations per family per year.

NURSE CONSULTATIONS

The nurse at your nearest Alpha Pharm, Clicks, Dis-Chem, Local Choice, Medicare or Pick n Pay pharmacy clinic can treat minor ailments. In many practices, the nurse can prescribe up to schedule 2 medication.
Prescribed medication has no rand amount limit if it’s on the approved formulary.
Nurse, GP and virtual GP consultations have a combined limit to 5 consultations per family per year.

VIRTUAL 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 consultations are available at approved pharmacy clinics only, namely Alpha Pharm, Dis-Chem and Medicare.
Virtual GP, nurse and GP consultations have a combined limit of 5 consultations per family per year.

MEDICINE COVER

ACUTE MEDICATION

DISPENSING NETWORK GP

Have a chest infection or flu? Your network GP can provide medication for every-day illnesses and will give you the medication that you need.
Acute medication that you get in the rooms has no rand amount limit.

NON-DISPENSING NETWORK GP

If your network GP doesn’t provide medication in the rooms, you’ll be given a prescription.
Go to any Mediscor pharmacy, like Alpha Pharm, Clicks, Dis-Chem, Local Choice, Medicare or Pick n Pay to collect your medication.
Acute medication that your non-dispensing network GP prescribes has no rand amount limit.

APPROVED MEDICINE FORMULARY
The medication that your network GP, the nurse or specialist prescribes will be covered if it’s on the approved Mediscor formulary.

A formulary is an approved list of medicines that Unity Health has agreed to cover in full. Visit Mediscor’s website at
www.mediscor.co.za to see which acute medication is covered.

CHRONIC MEDICATION

You’re covered for chronic medication that your network GP prescribes from the Mediscor formulary for the following  chronic conditions or diseases:

•asthma; •chronic obstructive pulmonary disorder;
•diabetes mellitus type 1 & 2; • Epilepsy;
•hypertension; •hyperlipidemia;
•HIV/AIDS; and •tuberculosis.

    Your network GP will help to get you registered on the Chronic Medication Programme with Mediscor. To see which chronic medication is covered, visit Mediscor’s website at www.mediscor.co.za.

    Once you’re registered to receive chronic medication, delivery of your medication will be arranged with you.

    If you prefer, you can collect your chronic medication from any Mediscor pharmacy, like Alpha Pharm, Clicks, Dis-Chem,
    Local Choice, Medicare or Pick n Pay.

    BLOOD & X-RAY COVER

    BLOOD TESTS AND X-RAYS

    When you need a blood test, like a cholesterol or glucose test, your network GP will refer you to the nearest Ampath, Lancet or PathCare pathology facility.

    You’ll also be 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 positive test per person per year

    Basic black-and-white x-rays, like a chest x-ray, are covered when your network GP refers you to a radiology facility during one of your visits.

    There is no rand amount limit on blood tests and x-rays, as long as it’s on the approved list of codes.

    Specialised radiology, like MRI and CT scans, aren’t covered.

    LIFESTYLE BENEFIT

    Our Lifestyle Benefit is complimentary and doesn’t cost you a cent.

    EXTRA HIGH SCHOOL LEARNING SUPPORT

    Based on the CAPS curriculum, your Gr.8 to Gr.12 high school child gets instant access to content that’ll help them study, improve their knowledge and boost their marks. Read more…

    This value-add benefit is offered by Stratum Benefits. It’s not administered by Unity Health or underwritten by Constantia Insurance Company Limited.

    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 20 or less employees join, or when it’s voluntary for employees to join, the following waiting periods will apply.

    1 MONTH GENERAL WAITING PERIOD
    You don’t have cover during this period for the Day-to-Day Benefits.

    12 MONTH CHRONIC MEDICATION WAITING PERIOD

    GENERAL EXCLUSIONS

    We don’t cover healthcare or service providers’ accounts related to any medical procedure, treatment, hospitalisation, illness, disease, loss, damage, death, bodily injury or liability for:

    1. events that occurred when you were not an insured person.
    2. events that occur during a policy waiting period, unless it is for accidental events or medical emergencies, where applicable.
    3. events where your policy’s benefit limits have been reached.
    4. events where your policy does not provide an appropriate benefit to claim from.
    5. events where you did not obtain pre-authorisation, or where an appropriate healthcare provider referral was not obtained.
    6. events where the healthcare or service providers that you have used do not form part of the provider network.
    7. healthcare services, procedures or medication that do not form part of the list of approved tariff codes or formularies, where  applicable.
    8. events where more than one general practitioner, nurse, or virtual general practitioner consultation was accessed on the same day  for the same insured person.
    9. costs that, in the opinion of the Underwriting Manager’s clinical review team:
    9.1 are not medically necessary or clinically appropriate;
    9.2 do not meet the healthcare needs of the insured person; or
    9.3 are not consistent in type, frequency, or duration of treatment.
    10. reconstructive cosmetic or maxillo-facial surgery, including related medical conditions or procedures.
    11. obesity or its sequel, cosmetic surgery or surgery directly or indirectly caused by, related to, or in consequence of cosmetic surgery.
    12. external prosthetic devices or external medical items, like artificial limbs and wheelchairs.
    13. artificial insemination, infertility treatment or contraceptives.
    14. robotic surgery, specialised mechanical or computerised appliances, or equipment.
    15. routine physical, procedures of a purely diagnostic nature or any other examination where there’s no objective indication of impairment in normal health, including laboratory diagnostic or x-ray examinations, unless in the course of a medical condition or  disability established by prior call or attendance of a medical practitioner.
    16. riots, wars, political acts, public disorder, terrorism, civil commotions, labour disturbances, strikes, lock-out, or any attempted such acts.
    17. 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.
    18. attempted suicide, intentional self-injury or deliberate exposure to exceptional danger unless it’s in an attempt to save a human life.
    19. events where the use of drugs, narcotics or alcohol are involved, including any illness or addiction caused by using such substances.
    20. participation in:
    20.1 active military, police or police reservist duty;
    20.2 aviation, other than as a passenger;
    20.3 any competitive or professional sport or activity; or
    20.4 any form of race or speed test, unless it’s on foot or involves any non-mechanically propelled vehicle, vessel, craft or aircraft.
    21. nuclear weapons material, ionising radiations or contamination by radioactivity from any nuclear fuel, nuclear waste or from the combustion of nuclear fuel that includes any self-sustaining process of nuclear fission.
    22. events that occur for which the actual damage is provided for by legislation, including contractual liability and consequential loss.
    23. non-disclosure of material information that is likely to affect the assessment or acceptance of risk.
    24. dual insurance where cover is provided by more than one health insurance policy through different insurers, or through the same insurer.