EMERGENCY & ACCIDENT BENEFIT OPTION

 

EMERGENCY & ACCIDENT BENEFIT OPTION

 

Unity Health has contracted with some of the major hospital groups to ensure you get the cover you need when it matters most.

You’re covered for emergencies and accidents at your nearest private hospital and the hospital’s casualty facility, but we don’t cover planned medical procedures, like childbirth or having cataracts removed.

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 | EMERGENCY & ACCIDENT BENEFIT OPTION PREMIUMS FOR INDIVIDUALS

If you’re 61 or older applying for cover on the Emergency & Accident 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 Emergency & Accident Benefit Option as a stand-alone product, the following premiums will apply:

ENTRY AGE

 

 

EMERGENCY & ACCIDENT BENEFIT OPTION PREMIUMS FOR INDIVIDUALS
PRINCIPAL INSURED SPOUSE ADULT DEPENDANT

CHILD DEPENDANT

 

60 or younger R 167 R   90 R 90 R 37
61 or older R 210 R 133

Unity Health has contracted with some of the major hospital groups to ensure you get the cover you need when it matters most.

You’re covered for emergencies and accidents at your nearest private hospital and the hospital’s casualty facility, but we don’t cover planned medical procedures, like childbirth or having cataracts removed.

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 | EMERGENCY & ACCIDENT BENEFIT OPTION PREMIUMS FOR INDIVIDUALS

If you’re 61 or older applying for cover on the Emergency & Accident 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 Emergency & Accident Benefit Option as a stand-alone product, the following premiums will apply:

 

EMERGENCY & ACCIDENT BENEFIT OPTION PREMIUMS FOR INDIVIDUALS

 

 

PRINCIPAL INSURED
60 or younger R 167
61 or older R 210

 

 

SPOUSE
60 or younger R   90
61 or older R 133

 

 

ADULT DEPENDANT
60 or younger R 90
61 or older

 

 

CHILD DEPENDANT

 

60 or younger R 37
61 or older

HOSPITAL CARE

EMERGENCY COVER

What is a medical emergency? It’s an unexpected event or health condition, like a heart attack or stroke, that can result in serious bodily impairment or death if you don’t receive immediate treatment.

We’ll cover the cost to transport you to your nearest private hospital and the cost to be hospitalised when you’re admitted as an in-patient for stabilisation after a medical emergency.

You must get pre-authorisation for the event as this will help with a smooth admission into hospital.

Limited to R 25 000 per person per event.

We don’t cover medical procedures that you need after being admitted to hospital, like a heart bypass. We’ll only cover the cost to get you stabilised. If you need further treatment after stabilisation, we’ll cover the cost to transfer you to a public hospital. Any hospital costs thereafter will be for your own pocket.

ACCIDENT COVER

If you’re involved in an accident, like a motor vehicle accident, and need medical treatment for the physical injuries you’ve sustained, we’ll cover the cost to get you admitted at your nearest private hospital and we’ll cover the cost of all the related healthcare providers who treat you.

You must get pre-authorisation for the event.

Limited to R 1 200 000 per person per event.

What is an accidental event? It’s an event that requires immediate medical treatment due to physical injury caused by physical impact, like a motor vehicle accident.

CASUALTY VISITS

For immediate medical treatment due to an accident you can go to the casualty facility at your nearest private hospital.

You must get pre-authorisation for the event.

Limited to R 6 500 per person per event.

MRI AND CT SCANS

When you’re admitted to hospital for a physical injury caused by an accident, we’ll cover the cost of an MRI or CT scan.

You must get pre-authorisation before you go for a scan.

Limited to R 17 000 per person per year.

PHYSICAL REHABILITATION CARE

Need physical therapy for an injury caused by an accident?

We’ll cover the cost of the therapy you receive from a physiotherapist or occupational therapist after you’re discharged from hospital due to an accident.

You must get pre-authorisation before your treatment starts.

Limited to R 3 250 per person per year.

This benefit doesn’t apply if you weren’t hospitalised due to an accident.
You must receive therapy or treatment within 3 months from the date that you are discharged from hospital.

24-HOUR MEDICAL EMERGENCY SERVICES

Our 24-hour national emergency contact centre can assist with the following services in the event of a medical emergency:

  • ambulance transfers between hospitals;
  • emergency transport services by air or road;
  • repatriation of a loved one’s mortal remains within the borders of South Africa, limited to R 7 500 per policy per year; and
  • telephonic medical advice.
  • PAYOUT BENEFIT

    ACCIDENTAL DEATH

    You and your registered spouse are covered for a benefit amount of R 15 000 per person if either one of you passes away due to an accident.

    You must nominate a beneficiary to receive the benefit.

    HOSPITAL CARE

    EMERGENCY COVER

    What is a medical emergency? It’s an unexpected event or health condition, like a heart attack or stroke, that can result in serious bodily impairment or death if you don’t receive immediate treatment.

    We’ll cover the cost to transport you to your nearest private hospital and the cost to be hospitalised when you’re admitted as an in-patient for stabilisation after a medical emergency.

    You must get pre-authorisation for the event as this will help with a smooth admission into hospital.

    Limited to R 25 000 per person per event.

    We don’t cover medical procedures that you need after being admitted to hospital, like a heart bypass. We’ll only cover the cost to get you stabilised. If you need further treatment after stabilisation, we’ll cover the cost to transfer you to a public hospital. Any hospital costs thereafter will be for your own pocket.

    ACCIDENT COVER

    If you’re involved in an accident, like a motor vehicle accident, and need medical treatment for the physical injuries you’ve sustained, we’ll cover the cost to get you admitted at your nearest private hospital and we’ll cover the cost of all the related healthcare providers who treat you.

    You must get pre-authorisation for the event.

    Limited to R 1 200 000 per person per event.

    What is an accidental event? It’s an event that requires immediate medical treatment due to physical injury caused by physical impact, like a motor vehicle accident.

    CASUALTY VISITS

    For immediate medical treatment due to an accident you can go to the casualty facility at your nearest private hospital.

    You must get pre-authorisation for the event.

    Limited to R 6 500 per person per event.

    MRI AND CT SCANS

    When you’re admitted to hospital for a physical injury caused by an accident, we’ll cover the cost of an MRI or CT scan.

    You must get pre-authorisation before you go for a scan.

    Limited to R 17 000 per person per year.

    PHYSICAL REHABILITATION CARE

    Need physical therapy for an injury caused by an accident?

    We’ll cover the cost of the therapy you receive from a physiotherapist or occupational therapist after you’re discharged from hospital due to an accident.

    You must get pre-authorisation before your treatment starts.

    Limited to R 3 250 per person per year.

    This benefit doesn’t apply if you weren’t hospitalised due to an accident.
    You must receive therapy or treatment within 3 months from the date that you are discharged from hospital.

    24-HOUR MEDICAL EMERGENCY SERVICES

    Our 24-hour national emergency contact centre can assist with the following services in the event of a medical emergency:

    • ambulance transfers between hospitals;
    • emergency transport services by air or road;
    • repatriation of a loved one’s mortal remains within the borders of South Africa, limited to R 7 500 per policy per year; and
    • telephonic medical advice.

    PAYOUT BENEFIT

    ACCIDENTAL DEATH

    You and your registered spouse are covered for a benefit amount of R 15 000 per person if either one of you passes away due to an accident.

    You must nominate a beneficiary to receive the benefit.

    WELLNESS BENEFITS

    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 BENEFIT

    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 don’t apply to the Emergency & Accident Benefit Option.

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

    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.

    WELLNESS BENEFITS

    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 BENEFIT

    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.

    WAITING PERIODS AND GENERAL EXCLUSIONS

    WAITING PERIODS

    Waiting periods don’t apply to the Emergency & Accident Benefit Option.

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

    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.