DAY-TO-DAY BENEFIT OPTION

 

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.

Visit practice.unitywellness.co.za or call us on 011 781-4488 to find the nearest provider.

Unity Health has contracted with the following pharmacies:

OPEN ENROLMENT, COMMUNITY RATING AND CROSS-SUBSIDISATION

The Health Insurance options 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 that all premiums received are paid into one risk pool from where claims are paid.

ESSENTIAL PRIMARY PLUS | DAY-TO-DAY BENEFIT OPTION PREMIUMS FOR INDIVIDUALS

If you’re 56 or older and apply for cover on the Day-to-Day Benefit Option, you’ll pay a higher premium unless you can prove that you’ve been on medical aid or primary healthcare insurance cover for 15 or more consecutive years from the age of 35.

Children aged 20 years or younger pay child dependant premiums.

Children aged 21 years or older can be added to your policy and remain on your policy if they are full-time students or if they are financially dependent on you, and proof is submitted every year. Children aged 21 years or older pay adult dependant premiums.

WHAT PROOF CAN BE SUBMITTED?
We accept proof from the educational facility or stamped copies of your child’s bank account statements of the past 3 months.

Joining as a family? One Health Insurance policy covers you, your spouse, and any child dependant as long as you are their parent or legal guardian.

If you take the Day-to-Day Benefit Option as a stand-alone product, the following premiums will apply:

ENTRY AGE

 

 

DAY-TO-DAY BENEFIT OPTION PREMIUMS FOR INDIVIDUALS
PRINCIPAL INSURED SPOUSE ADULT DEPENDANT


CHILD DEPENDANT

 

55 or younger R 390 R 260 R 260 R 115
56 or older R 573 R 443

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.

Visit www.practice.unitywellness.co.za or contact us to find your nearest provider.

Unity Health has contracted with the following pharmacies:

OPEN ENROLMENT, COMMUNITY RATING AND CROSS-SUBSIDISATION

The Health Insurance options 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 that all premiums received are paid into one risk pool from where claims are paid.

ESSENTIAL PRIMARY PLUS | DAY-TO-DAY BENEFIT OPTION PREMIUMS FOR INDIVIDUALS

If you’re 56 or older and apply for cover on the Day-to-Day Benefit Option, you’ll pay a higher premium unless you can prove that you’ve been on medical aid or primary healthcare insurance cover for 15 or more consecutive years from the age of 35.

Children aged 20 years or younger pay child dependant premiums.

Children aged 21 years or older can be added to your policy and remain on your policy if they are full-time students or if they are financially dependent on you, and proof is submitted every year. Children aged 21 years or older pay adult dependant premiums.

WHAT PROOF CAN BE SUBMITTED?
We accept proof from the educational facility or stamped copies of your child’s bank account statements of the past 3 months.

Joining as a family? One Health Insurance policy covers you, your spouse, and any child dependant as long as you are their parent or legal guardian.

If you take the Day-to-Day Benefit Option as a stand-alone product, the following premiums will apply:

 

DAY-TO-DAY BENFITS OPTION PREMIUMS FOR INDIVIDUALS 

 

 

PRINCIPAL INSURED
55 or younger R 390
56 or older R 573

 

 

SPOUSE
55 or younger R 260
56 or older R 443

 

 

ADULT DEPENDANT
55 or younger R 260
56 or older

 

 

CHILD DEPENDANT

 

55 or younger R 115
56 or older

GP CONSULTATIONS AND MEDICAL PROCEDURES

This benefit covers unlimited consultations at any network GP.

We also cover basic medical or surgical procedures that your network GP performs in their rooms, like stitching of a wound or applying a cast to a broken arm.

Treatment must be provided according to an approved list of tariff codes.

For the 10th visit and every visit thereafter, pre-authorisation is required per person per year.

NURSE CONSULTATIONS

The nurse at your nearest Clicks, Dis-Chem, Pick n Pay, Local Choice or Medicare pharmacy can treat minor illnesses. In many practices the nurse can prescribe up to schedule 2 medication.

Nurse consultations and prescribed medication are unlimited.

For the 10th combined nurse or virtual GP consultation, and for every visit thereafter, pre-authorisation is required per person per year.

VIRTUAL GP CONSULTATIONS

Virtual network GP consultations through a video conference link can be facilitated by the nurse.

Virtual consultations are unlimited and is available at approved pharmacies only, like Dis-Chem and Medicare.

For the 10th combined nurse or virtual GP consultation, and for every visit thereafter, pre-authorisation is required per person per year.

SPECIALIST CONSULTATIONS

When you need to see a specialist for specialised medical treatment or advice, your network GP must refer you and you must get pre-authorisation before you see the specialist.

We’ll refund the cost of the consultation up to R 1 275 per visit to a maximum of R 2 650 per family per year.

If your specialist refers you for blood tests or x-rays that form part of our approved list of tariff codes, we’ll cover the cost of the tests or x-rays from the BLOOD TESTS & X-RAYS BENEFIT.

If your specialist prescribes acute medication that forms part of our formulary, we’ll cover it under the ACUTE MEDICATION BENEFIT. If the medication doesn’t form part of our formulary it will be covered subject to the benefit limit of the SPECIALIST CONSULTATIONS BENEFIT.

PRE-BIRTH CONSULTATIONS

Hey, soon-to-be-mommy… we’ll refund you for 2 gynaecologist visits and 2 ultrasound scans when you visit any gynaecologist of your choice.

You must get pre-authorisation before you go.

Limited to R 3 250 per family per year.

Ask your network GP about having the scans done in the rooms, but remember, the benefit limit for PRE-BIRTH CONSULTATIONS will apply.

GP CONSULTATIONS AND MEDICAL PROCEDURES

This benefit covers unlimited consultations at any network GP.

We also cover basic medical or surgical procedures that your network GP performs in their rooms, like stitching of a wound or applying a cast to a broken arm.

Treatment must be provided according to an approved list of tariff codes.

For the 10th visit and every visit thereafter, pre-authorisation is required per person per year.

NURSE CONSULTATIONS

The nurse at your nearest Clicks, Dis-Chem, Pick n Pay, Local Choice or Medicare pharmacy can treat minor illnesses. In many practices the nurse can prescribe up to schedule 2 medication.

Nurse consultations and prescribed medication are unlimited.

For the 10th combined nurse or virtual GP consultation, and for every visit thereafter, pre-authorisation is required per person per year.

VIRTUAL GP CONSULTATIONS

Virtual network GP consultations through a video conference link can be facilitated by the nurse.

Virtual consultations are unlimited and is available at approved pharmacies only, like Dis-Chem and Medicare.

For the 10th combined nurse or virtual GP consultation, and for every visit thereafter, pre-authorisation is required per person per year.

SPECIALIST CONSULTATIONS

When you need to see a specialist for specialised medical treatment or advice, your network GP must refer you and you must get pre-authorisation before you see the specialist.

We’ll refund the cost of the consultation up to R 1 275 per visit to a maximum of R 2 650 per family per year.

If your specialist refers you for blood tests or x-rays that form part of our approved list of tariff codes, we’ll cover the cost of the tests or x-rays from the BLOOD TESTS & X-RAYS BENEFIT.

If your specialist prescribes acute medication that forms part of our formulary, we’ll cover it under the ACUTE MEDICATION BENEFIT. If the medication doesn’t form part of our formulary it will be covered subject to the benefit limit of the SPECIALIST CONSULTATIONS BENEFIT.

PRE-BIRTH CONSULTATIONS

Hey, soon-to-be-mommy… we’ll refund you for 2 gynaecologist visits and 2 ultrasound scans when you visit any gynaecologist of your choice.

You must get pre-authorisation before you go.

Limited to R 3 250 per family per year.

Ask your network GP about having the scans done in the rooms, but remember, the benefit limit for PRE-BIRTH CONSULTATIONS will apply.

MEDICINE COVER

ACUTE MEDICATION

DISPENSING NETWORK GP

Have a chest infection or flu? We cover medication for every-day illnesses that your dispensing network GP provides in the rooms.

Acute medication that you receive in the rooms from your dispensing network GP is unlimited.

NON-DISPENSING NETWORK GP

If your network GP doesn’t dispense medication from the rooms, you’ll be given a prescription. You can collect your medication from any Mediscor pharmacy, like Clicks, Dis-Chem, Pick n Pay, Local Choice or Medicare.

Acute medication that your non-dispensing network GP prescribes is unlimited.

Medication that’s given to you in the rooms or that’s prescribed must be from the approved Mediscor formulary.
A formulary is an approved list of medicines that Unity Health has agreed to cover in full.

CHRONIC MEDICATION

We cover chronic medication that your network GP prescribes from the Mediscor formulary for the following chronic conditions or diseases:

  • asthma;
  • chronic obstructive pulmonary disorder;
  • diabetes type 1 & 2;
  • epilepsy;
  • hyperlipidaemia;
  • hypertension;
  • 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 we cover, visit Mediscor’s website at  www.mediscor.net.

Once you’re registered to receive chronic medication, Medipost will contact you to arrange a delivery date and collection point. Deliveries are managed by MediLogistics and can be done at either your home, place of work or your network GP’s rooms.

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

EMPLOYER GROUPS: We cover an additional 19 chronic conditions or diseases for employees who belong to the Day-to-Day Benefit Option as part of an employer group:

Addison’s disease; bi-polar mood disorder; bronchiectasis; cardiac failure; cardiomyopathy disease; chronic renal disease; coronary artery disease; Crohn’s disease; diabetes insipidus; dysrhythmias; glaucoma; haemophilia; hypothyroidism; multiple sclerosis; Parkinson’s disease; rheumatoid arthritis; schizophrenia; systemic lupus erythematosus; and ulcerative colitis.

BLOOD TESTS AND X-RAYS

Blood tests, like a cholesterol or glucose test are covered when your network GP refers you to the nearest Ampath, Lancet or PathCare pathology facility.

We also cover basic black-and-white x-rays, like a chest x-ray, when you’re referred to a radiology facility during one of your visits.

Blood tests and x-rays are unlimited and are subject to a list of approved tariff codes.

We don’t cover specialised radiology like MRI and CT scans.

DENTAL CARE

Visit any dentist of your choice when you need basic dental treatment, like:

  • full mouth examinations;
  • extractions;
  • fillings;
  • intra-oral radiographs; or
  • scaling and polishing.

When you need emergency dental treatment to drain an abscess or root canal treatment, or urgent dental treatment when an accident causes you to lose a tooth or damages your teeth, we’ve got you covered for that too.

All dental procedures are covered according to an approved list of tariff codes and you must get pre-authorisation before you go.

Limited to R 1 275 per person per event.

Call us on 011 781-4488 if you prefer to use a recommended dentist on the Unity Health dentist network. We’ll help you find one.

Specialised dentistry like bridgework, crowns, dentures, and orthodontic treatment aren’t covered.

Visit practice.unitywellness.co.za or call us on 011 781-4488 if you prefer to use a recommended dentist on the Unity Health dentist network.  We’ll help you find one.

EYE CARE

You can visit your nearest PPN optometrist for an eye test, frame or lenses.

We cover you for:

  • 1 eye test per person every 2 years;
  • 1 standard frame to the value of R 254 per person every 2 years; or
  • 1 pair of clear, standard spectacle lenses per person every 2 years.

Our eye care benefits are provided through PPN, the largest optical network in the country.

To find your nearest provider, visit www.ppn.co.za or call us on 011 781-4488.

We don’t cover optional extras, like tinting or scratch resistant coatings.

WELLNESS BENEFITS

Dis-Chem, Clicks, Pick n Pay, Local Choice or Medicare pharmacy are approved network providers for your wellness assessment, preventative tests, or vaccinations.

WELLNESS ASSESSMENT

You’re covered for 1 wellness assessment per person per year which includes the following basic health checks:

  • blood pressure;
  • body mass index;
  • cholesterol;
  • glucose levels;
  • HIV/AIDS, which includes counselling before and after testing; and
  • waist circumference.

EMPLOYER GROUPS: If you’re an employee of a registered employer group, you’re covered for 1 wellness assessment when an Employee Wellness Day is scheduled for 15 or more employees. You can have the same health checks done on-site.

You also have access to the following additional health checks during an Employee Wellness Day: 

  • breast screening using a BreastlightTM device for all female employees;
  • eye test;
  • prostate specific antigen (PSA) screening once every 2 years for male employees aged 50 years or older; and
  • tuberculosis rapid test for all high-risk employees.

 
If you’re unable to attend the on-site wellness day at your company, you can visit your nearest Clicks, Dis-Chem, Pick n Pay, Local Choice or Medicare pharmacy to have the basic health checks or PSA screening done.

Good to know: The dependants registered on your Health Insurance policy can have their basic health checks or PSA screening done after the General Waiting Period applicable to them.

PREVENTATIVE CARE

Take care of yourself with 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 once every 5 years for individuals 60 years or older or for individuals with a medically proven compromised immune system;
  • 1 hepatitis A and B vaccination once-off per person; or
  • 1 tetanus vaccination per person once every 10 years.

 
TESTS & SCREENINGS 

  • 1 pap smear once every 3 years for females aged 21 years or older; or
  • 1 prostate specific antigen screening once every 2 years for males aged 50 years or older.

 
You can ask your network GP about having a pap smear done in the rooms during one of your visits.

ESSENTIAL ASSISTANCE PROGRAMME (EAP)

Our wellness partner, Reality Wellness Group, offers unlimited 24/7 telephonic advice and counselling services for:

  • financial advice;
  • legal advice;
  • HIV/AIDS counselling; and
  • trauma counselling.

 
Good to know: Skype counselling sessions can be arranged.

We don’t cover face-to-face counselling. This will be for your own pocket.

LIFESTYLE BENEFITS

Our Lifestyle Benefits are complimentary and don’t cost you a cent.

FUEL REWARDS

Fill up at any SHELL service station and get rewarded with 22 cents per litre of diesel and 15 cents per litre of petrol. Subject to change without prior notice.

Read more…

WAITING PERIODS AND GENERAL EXCLUSIONS

WAITING PERIODS

Waiting periods apply from the start date of your policy and from each insured person’s cover start date.

Waiting periods don’t apply to the Essential Assistance Programme (EAP).

2 MONTH GENERAL WAITING PERIOD
You don’t have cover during this period for the Day-to-Day, Wellness Assessment or Preventative Care Benefits.

9 MONTH PRE-BIRTH CONSULTATION WAITING PERIOD
12 MONTH CHRONIC MEDICATION WAITING PERIOD
12 MONTH EYE CARE WAITING PERIOD

EMPLOYER GROUPS: 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 above waiting periods will apply, however, the 2 MONTH GENERAL WAITING PERIOD will reduce to a 1 MONTH GENERAL WAITING PERIOD.

Health Insurance isn’t medical aid cover, doesn’t provide similar cover as that of a medical aid and can’t be substituted for medical aid membership.

GENERAL EXCLUSIONS

GENERAL EXCLUSIONS APPLICABLE TO THE DAY-TO-DAY BENEFIT OPTION, EMERGENCY & ACCIDENT BENEFIT OPTION AND DAY-TO-DAY, EMERGENCY & ACCIDENT BENEFIT OPTION

We do not 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 weren’t an insured person.
2. events that occur during a policy waiting period unless it’s for accidental events or medical emergencies, where applicable.
3. events where your policy’s benefit limits have been reached.
4. events where your policy doesn’t provide an appropriate benefit to claim from.
5. events where you didn’t obtain pre-authorisation, or where an appropriate healthcare provider referral wasn’t obtained.
6. events where the healthcare or service providers that you’ve used don’t form part of the provider network, unless your policy has a benefit that covers it.
7. healthcare services, procedures or medication that don’t form part of the list of approved tariff codes or formularies, where applicable.
8. out-patient consultations related to allied healthcare providers, like physiotherapists and speech therapists pertaining to the SPECIALIST CONSULTATION BENEFIT.
9. eye care, other than an eye test, a frame or spectacle lenses covered under the EYE CARE BENEFIT.
10. in-patient or out-patient hospital or casualty admissions where the medical events weren’t due to accidental events or emergencies, where applicable.
11. medical procedures performed as part of in-patient stabilisation, unless it’s for the cost of stabilisation required in the event of an emergency where the medical event is the result of a sudden, and at the time unexpected onset of a        medical condition that requires immediate medical treatment.
12. MRI or CT scans, unless it’s due to accidental events.
13. medical transportation if it’s not for emergency purposes.
14. physiotherapy or occupational therapy for physical rehabilitation:
a. that’s not due to accidental events; or
b. that’s not provided within 3 months after you’ve been discharged from hospital.
15. costs incurred for the voluntary stay at a private facility after stabilisation for a medical emergency.
16. 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.
17. reconstructive cosmetic or maxillo-facial surgery, including related medical conditions or procedures that don’t form part of an authorised hospital event due to an accident.
18. obesity or its sequel, cosmetic surgery or surgery directly or indirectly caused by, related to, or in consequence of cosmetic surgery, unless your policy has a benefit that covers it.
19. external prosthetic devices or external medical items, like artificial limbs and wheelchairs.
20. artificial insemination, infertility treatment or contraceptives.
21. robotic surgery, specialised mechanical or computerised appliances, or equipment.
22. 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.
23. riots, wars, political acts, public disorder, terrorism, civil commotions, labour disturbances, strikes, lock-out, or any attempted such acts.
24. 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.
25. attempted suicide, intentional self-injury or deliberate exposure to exceptional danger unless it’s in an attempt to save a human life.
26. events where the use of drugs, narcotics or alcohol are involved, including any illness or addiction caused by using such substances.
27. participation in:
a. active military, police or police reservist duty;
b. aviation, other than as a passenger;
c. hazardous, competitive or professional sports or activities; or
d. any form of race or speed test, unless it’s on foot or involves any non-mechanically propelled vehicle, vessel, craft or aircraft.
28. nuclear weapons material, ionising radiations and/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.
29. events that occur for which the actual damage is provided for by legislation, including contractual liability and consequential loss.
30. non-disclosure of material information that is likely to affect the assessment or acceptance of risk.
31. dual insurance where cover is provided by more than one health insurance policy through different insurers, or through the same insurer.
 

These Health Insurance benefit options aren’t medical aid options, don’t provide similar cover as that of a medical aid and can’t be substituted for medical aid membership.

MEDICINE COVER

ACUTE MEDICATION

DISPENSING NETWORK GP

Have a chest infection or flu? We cover medication for every-day illnesses that your dispensing network GP provides in the rooms.

Acute medication that you receive in the rooms from your dispensing network GP is unlimited.

NON-DISPENSING NETWORK GP

If your network GP doesn’t dispense medication from the rooms, you’ll be given a prescription. You can collect your medication from any Mediscor pharmacy, like Clicks, Dis-Chem, Pick n Pay, Local Choice or Medicare.

Acute medication that your non-dispensing network GP prescribes is unlimited.

Medication that’s given to you in the rooms or that’s prescribed must be from the approved Mediscor formulary.
A formulary is an approved list of medicines that Unity Health has agreed to cover in full.

CHRONIC MEDICATION

We cover chronic medication that your network GP prescribes from the Mediscor formulary for the following chronic conditions or diseases:

  • asthma;
  • chronic obstructive pulmonary disorder;
  • diabetes type 1 & 2;
  • epilepsy;
  • hyperlipidaemia;
  • hypertension;
  • 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 we cover, visit Mediscor’s website at  www.mediscor.net.

Once you’re registered to receive chronic medication, Medipost will contact you to arrange a delivery date and collection point. Deliveries are managed by MediLogistics and can be done at either your home, place of work or your network GP’s rooms.

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

EMPLOYER GROUPS: We cover an additional 19 chronic conditions or diseases for employees who belong to the Day-to-Day Benefit Option as part of an employer group:

Addison’s disease; bi-polar mood disorder; bronchiectasis; cardiac failure; cardiomyopathy disease; chronic renal disease; coronary artery disease; Crohn’s disease; diabetes insipidus; dysrhythmias; glaucoma; haemophilia; hypothyroidism; multiple sclerosis; Parkinson’s disease; rheumatoid arthritis; schizophrenia; systemic lupus erythematosus; and ulcerative colitis.

BLOOD TESTS AND X-RAYS

Blood tests, like a cholesterol or glucose test are covered when your network GP refers you to the nearest Ampath, Lancet or PathCare pathology facility.

We also cover basic black-and-white x-rays, like a chest x-ray, when you’re referred to a radiology facility during one of your visits.

Blood tests and x-rays are unlimited and are subject to a list of approved tariff codes.

We don’t cover specialised radiology like MRI and CT scans.

DENTAL CARE

Visit any dentist of your choice when you need basic dental treatment, like:

  • full mouth examinations;
  • extractions;
  • fillings;
  • intra-oral radiographs; or
  • scaling and polishing.

When you need emergency dental treatment to drain an abscess or root canal treatment, or urgent dental treatment when an accident causes you to lose a tooth or damages your teeth, we’ve got you covered for that too.

All dental procedures are covered according to an approved list of tariff codes and you must get pre-authorisation before you go.

Limited to R 1 275 per person per event.

Call us on 011 781-4488 if you prefer to use a recommended dentist on the Unity Health dentist network. We’ll help you find one.

Specialised dentistry like bridgework, crowns, dentures, and orthodontic treatment aren’t covered.

Visit practice.unitywellness.co.za or call us on 011 781-4488 if you prefer to use a recommended dentist on the Unity Health dentist network.  We’ll help you find one.

EYE CARE

You can visit your nearest PPN optometrist for an eye test, frame or lenses.

We cover you for:

  • 1 eye test per person every 2 years;
  • 1 standard frame to the value of R 254 per person every 2 years; or
  • 1 pair of clear, standard spectacle lenses per person every 2 years.

Our eye care benefits are provided through PPN, the largest optical network in the country.

To find your nearest provider, visit www.ppn.co.za or call us on 011 781-4488.

We don’t cover optional extras, like tinting or scratch resistant coatings.

WELLNESS BENEFITS

Dis-Chem, Clicks, Pick n Pay, Local Choice or Medicare pharmacy are approved network providers for your wellness assessment, preventative tests, or vaccinations.

WELLNESS ASSESSMENT

You’re covered for 1 wellness assessment per person per year which includes the following basic health checks:

  • blood pressure;
  • body mass index;
  • cholesterol;
  • glucose levels;
  • HIV/AIDS, which includes counselling before and after testing; and
  • waist circumference.

EMPLOYER GROUPS: If you’re an employee of a registered employer group, you’re covered for 1 wellness assessment when an Employee Wellness Day is scheduled for 15 or more employees. You can have the same health checks done on-site.

You also have access to the following additional health checks during an Employee Wellness Day: 

  • breast screening using a BreastlightTM device for all female employees;
  • eye test;
  • prostate specific antigen (PSA) screening once every 2 years for male employees aged 50 years or older; and
  • tuberculosis rapid test for all high-risk employees.

 
If you’re unable to attend the on-site wellness day at your company, you can visit your nearest Clicks, Dis-Chem, Pick n Pay, Local Choice or Medicare pharmacy to have the basic health checks or PSA screening done.

Good to know: The dependants registered on your Health Insurance policy can have their basic health checks or PSA screening done after the General Waiting Period applicable to them.

PREVENTATIVE CARE

Take care of yourself with 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 once every 5 years for individuals 60 years or older or for individuals with a medically proven compromised immune system;
  • 1 hepatitis A and B vaccination once-off per person; or
  • 1 tetanus vaccination per person once every 10 years.

 
TESTS & SCREENINGS 

  • 1 pap smear once every 3 years for females aged 21 years or older; or
  • 1 prostate specific antigen screening once every 2 years for males aged 50 years or older.

You can ask your network GP about having a pap smear done in the rooms during one of your visits.

ESSENTIAL ASSISTANCE PROGRAMME (EAP)

Our wellness partner, Reality Wellness Group, offers unlimited 24/7 telephonic advice and counselling services for:

  • financial advice;
  • legal advice;
  • HIV/AIDS counselling; and
  • trauma counselling.

Good to know: Skype counselling sessions can be arranged.

We don’t cover face-to-face counselling. This will be for your own pocket.

LIFESTYLE BENEFITS

Our Lifestyle Benefits are complimentary and don’t cost you a cent.

FUEL REWARDS

Fill up at any SHELL service station and get rewarded with 22 cents per litre of diesel and 15 cents per litre of petrol. Subject to change without prior notice.

Read more…

WAITING PERIODS AND GENERAL EXCLUSIONS

WAITING PERIODS

Waiting periods apply from the start date of your policy and from each insured person’s cover start date.

Waiting periods don’t apply to the Essential Assistance Programme (EAP).

2 MONTH GENERAL WAITING PERIOD
You don’t have cover during this period for the Day-to-Day, Wellness Assessment or Preventative Care Benefits.

9 MONTH PRE-BIRTH CONSULTATION WAITING PERIOD
12 MONTH CHRONIC MEDICATION WAITING PERIOD
12 MONTH EYE CARE WAITING PERIOD

EMPLOYER GROUPS: 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 above waiting periods will apply, however, the 2 MONTH GENERAL WAITING PERIOD will reduce to a 1 MONTH GENERAL WAITING PERIOD.

Health Insurance isn’t medical aid cover, doesn’t provide similar cover as that of a medical aid and can’t be substituted for medical aid membership.

GENERAL EXCLUSIONS

GENERAL EXCLUSIONS APPLICABLE TO THE DAY-TO-DAY BENEFIT OPTION, EMERGENCY & ACCIDENT BENEFIT OPTION AND DAY-TO-DAY, EMERGENCY & ACCIDENT BENEFIT OPTION

We do not 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 weren’t an insured person.
2. events that occur during a policy waiting period unless it’s for accidental events or medical emergencies, where applicable.
3. events where your policy’s benefit limits have been reached.
4. events where your policy doesn’t provide an appropriate benefit to claim from.
5. events where you didn’t obtain pre-authorisation, or where an appropriate healthcare provider referral wasn’t obtained.
6. events where the healthcare or service providers that you’ve used don’t form part of the provider network, unless your policy has a benefit that covers it.
7. healthcare services, procedures or medication that don’t form part of the list of approved tariff codes or formularies, where applicable.
8. out-patient consultations related to allied healthcare providers, like physiotherapists and speech therapists pertaining to the SPECIALIST CONSULTATION BENEFIT.
9. eye care, other than an eye test, a frame or spectacle lenses covered under the EYE CARE BENEFIT.
10. in-patient or out-patient hospital or casualty admissions where the medical events weren’t due to accidental events or emergencies, where applicable.
11. medical procedures performed as part of in-patient stabilisation, unless it’s for the cost of stabilisation required in the event of an emergency where the medical event is the result of a sudden, and at the time unexpected onset of a        medical condition that requires immediate medical treatment.
12. MRI or CT scans, unless it’s due to accidental events.
13. medical transportation if it’s not for emergency purposes.
14. physiotherapy or occupational therapy for physical rehabilitation:
a. that’s not due to accidental events; or
b. that’s not provided within 3 months after you’ve been discharged from hospital.
15. costs incurred for the voluntary stay at a private facility after stabilisation for a medical emergency.
16. 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.
17. reconstructive cosmetic or maxillo-facial surgery, including related medical conditions or procedures that don’t form part of an authorised hospital event due to an accident.
18. obesity or its sequel, cosmetic surgery or surgery directly or indirectly caused by, related to, or in consequence of cosmetic surgery, unless your policy has a benefit that covers it.
19. external prosthetic devices or external medical items, like artificial limbs and wheelchairs.
20. artificial insemination, infertility treatment or contraceptives.
21. robotic surgery, specialised mechanical or computerised appliances, or equipment.
22. 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.
23. riots, wars, political acts, public disorder, terrorism, civil commotions, labour disturbances, strikes, lock-out, or any attempted such acts.
24. 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.
25. attempted suicide, intentional self-injury or deliberate exposure to exceptional danger unless it’s in an attempt to save a human life.
26. events where the use of drugs, narcotics or alcohol are involved, including any illness or addiction caused by using such substances.
27. participation in:
a. active military, police or police reservist duty;
b. aviation, other than as a passenger;
c. hazardous, competitive or professional sports or activities; or
d. any form of race or speed test, unless it’s on foot or involves any non-mechanically propelled vehicle, vessel, craft or aircraft.
28. nuclear weapons material, ionising radiations and/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.
29. events that occur for which the actual damage is provided for by legislation, including contractual liability and consequential loss.
30. non-disclosure of material information that is likely to affect the assessment or acceptance of risk.
31. dual insurance where cover is provided by more than one health insurance policy through different insurers, or through the same insurer.
 

These Health Insurance benefit options aren’t medical aid options, don’t provide similar cover as that of a medical aid and can’t be substituted for medical aid membership.