ESSENTIAL PRIMARY PLUS
DAY-TO-DAY OPTION
ESSENTIAL PRIMARY PLUS
DAY-TO-DAY OPTION
WHO’S COVERED?
This health insurance policy covers you, your spouse and any child dependant of whom you are the parent or legal guardian.
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Through a national network of providers who’ve contracted with Unity Health, our health insurance administrator, you have access to more than 4 000 GPs and various pharmacies, pathologists, and radiologists.
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. Call us on 011 781 4488 for authorisation before you see the doctor.
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 2025.
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 310 per consultation, limited to 2 consultations per person per year.
Partners in Telemedicine:
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, Local Choice or Medicare pharmacy clinics are unlimited.
Download the Unity Health mobile app to find your nearest approved pharmacy with a nurse clinic that is partnered with Healthforce or AlphaDoc.
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.
NURSE CONSULTATIONS
The nurse at your nearest Alpha Pharm, Clicks, Dis-Chem, Local Choice or Medicare 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.
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 1 500 per consultation, limited to R 3 150 per family per year. This benefit will be pro-rated depending on your cover start date.
Call us on 011 781 4488 for pre-authorisation before you see the specialist.
If the specialist refers you for blood tests or x-rays that are on the list of approved codes, it will be covered from the BLOOD TESTS AND X-RAYS BENEFIT.
If it’s not on the list of approved codes, it will be covered from the SPECIALIST CONSULTATION BENEFIT up to the available benefit limit.
The ACUTE MEDICATION BENEFIT will cover medication that the specialist prescribes if it’s on the approved formulary.
If it’s not on the approved formulary, it will be covered from the SPECIALIST CONSULTATION BENEFIT up to the available benefit limit.
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 2 consultations and 2 ultrasound scans (2D), limited to R 3 800 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:
- asthma;
- chronic obstructive pulmonary disorder;
- diabetes type 1 & 2;
- epilepsy;
- hyperlipidaemia;
- hypertension;
- HIV/AIDS; and
- tuberculosis.
Your network GP can help to get you registered 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.
If you prefer, you may collect your chronic medication at any 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 have no benefit limit.
Specialised radiology, such as MRI and CT scans, aren’t covered.
DENTAL CARE
Visit any dentist for basic or emergency dental treatment.
Pre-authorisation for certain dental fillings is required.
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 R 1 375 per consultation and R 4 100 per family per year.
This benefit will be pro-rated 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 499 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 call us on 011 781-4488.
Optional extras, like tinting or scratch resistant coatings, aren’t covered.
WELLNESS BENEFITS
WELLNESS ASSESSMENT
Alpha Pharm, Clicks, Dis-Chem, Local Choice and Medicare pharmacy clinics are approved network providers for your wellness assessment.
You’re covered for 1 wellness assessment per person per year for the following basic health checks:
- blood pressure;
- body mass index;
- cholesterol;
- glucose levels;
- waist circumference; and
- HIV/AIDS, that includes counselling before and after testing.
PREVENTATIVE CARE
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 (Call us on 011 781 4488 for pre-authorisation before you go for this vaccination);
• 1 hepatitis A and B vaccination once-off per person; or
• 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 unlimited 24/7 telephonic advice and counselling services through Reality Wellness Group for:
- financial advice;
- legal advice;
- HIV/AIDS counselling; and
- trauma counselling.
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.
PREMIUMS FOR INDIVIDUALS
If you’re 56 years or older at the time of joining, you’ll pay a premium in the 56 or older category. If you submit proof of 15 credible years of medical aid membership or primary healthcare insurance cover from 35 years of age, with no break in cover of 3 or more months, you’ll pay a premium in the 55 or younger category.
Children who are 20 years or younger pay child dependant premiums.
Children between 21 and 25 years of age pay adult dependant premiums. From 26 years of age, child dependants must take out their own policy.
PREMIUMS FOR INDIVIDUALS
| ENTRY AGE | PRINCIPAL INSURED | SPOUSE | ADULT DEPENDANT | CHILD DEPENDANT |
| 55 or younger | R 410 | R 329 | R 329 | R 130 |
| 56 or older | R 619 | R 538 | — | — |
GP PRE-AUTH WAIVER
Add the GP PRE-AUTH WAIVER for R 39 per policy per month.
WAITING PERIODS AND GENERAL EXCLUSIONS
WAITING PERIODS
Waiting periods apply from your and your dependants’ cover start dates.
2 MONTH GENERAL WAITING PERIOD
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.
Health Insurance is not a medical aid, does not provide similar cover as medical aid and cannot be substituted for medical aid membership.
Through a national network of providers who’ve contracted with Unity Health, our health insurance administrator, you have access to more than 4 000 GPs and various pharmacies, pathologists, and radiologists.
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. Call us on 011 781 4488 for authorisation before you see the doctor.
GP PRE-AUTH WAIVER
Add the GP PRE-AUTH WAIVER for a small additional premium to see your network GP without prior approval.
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 310 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, Local Choice or Medicare pharmacy clinics are unlimited.
Download the Unity Health mobile app to find your nearest approved pharmacy with a nurse clinic that is partnered with Healthforce or AlphaDoc.
Partners in Telemedicine:
NURSE CONSULTATIONS
The nurse at your nearest Alpha Pharm, Clicks, Dis-Chem, Local Choice or Medicare 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.
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 1 500 per consultation, limited to R 3 150 per family per year. This benefit will be pro-rated depending on your cover start date.
Call us on 011 781 4488 for pre-authorisation before you see the specialist.
If the specialist refers you for blood tests or x-rays that are on the list of approved codes, it will be covered from the BLOOD TESTS AND X-RAYS BENEFIT.
If it’s not on the list of approved codes, it will be covered from the SPECIALIST CONSULTATION BENEFIT up to the available benefit limit.
The ACUTE MEDICATION BENEFIT will cover medication that the specialist prescribes if it’s on the approved formulary.
If it’s not on the approved formulary, it will be covered from the SPECIALIST CONSULTATION BENEFIT up to the available benefit limit.
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 2 consultations and 2 ultrasound scans (2D), limited to R 3 800 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:
- asthma;
- chronic obstructive pulmonary disorder;
- diabetes type 1 & 2;
- epilepsy;
- hyperlipidaemia;
- hypertension;
- HIV/AIDS; and
- tuberculosis.
Your network GP can help to get you registered 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 have no benefit limit.
Specialised radiology, such as MRI and CT scans, aren’t covered.
DENTAL CARE
Visit any dentist for basic or emergency dental treatment.
Pre-authorisation for certain dental fillings is required.
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 R 1 375 per consultation and R 4 100 per family per year.
This benefit will be pro-rated 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 499 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 call us on 011 781-4488.
Optional extras, like tinting or scratch resistant coatings, aren’t covered.
Partners in Optometry:
WELLNESS BENEFITS
WELLNESS ASSESSMENT
Alpha Pharm, Clicks, Dis-Chem, Local Choice and Medicare pharmacy clinics are approved network providers for your wellness assessment.
You’re covered for 1 wellness assessment per person per year for the following basic health checks:
- blood pressure;
- body mass index;
- cholesterol;
- glucose levels;
- waist circumference; and
- HIV/AIDS, that includes counselling before and after testing.
PREVENTATIVE CARE
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 (Call us on 011 781 4488 for pre-authorisation before you go for this vaccination);
• 1 hepatitis A and B vaccination once-off per person; or
• 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 unlimited 24/7 telephonic advice and counselling services through Reality Wellness Group for:
- financial advice;
- legal advice;
- HIV/AIDS counselling; and
- trauma counselling.
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.
PREMIUMS FOR INDIVIDUALS
If you’re 56 years or older at the time of joining, you’ll pay a premium in the 56 or older category. If you submit proof of 15 credible years of medical aid membership or primary healthcare insurance cover from 35 years of age, with no break in cover of 3 or more months, you’ll pay a premium in the 55 or younger category.
Children who are 20 years or younger pay child dependant premiums.
Children between 21 and 25 years of age pay adult dependant premiums. From 26 years of age, child dependants must take out their own policy.
WHO’S COVERED?
This health insurance policy covers you, your spouse and any child dependant of whom you are the parent or legal guardian.
PREMIUMS FOR INDIVIDUALS
| ENTRY AGE | PRINCIPAL INSURED |
| 55 or younger | R 410 |
| 56 or older | R 619 |
| ENTRY AGE | SPOUSE |
| 55 or younger | R 329 |
| 56 or older | R 538 |
| ADULT DEPENDANT | |
| – | R 329 |
| CHILD DEPENDANT | |
| – | R 130 |
WAITING PERIODS &
GENERAL EXCLUSIONS
WAITING PERIODS
Waiting periods apply from your and your dependants’ cover start dates.
2 MONTH GENERAL WAITING PERIOD
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.
