ESSENTIAL PRIMARY PLUS | EMERGENCY & ACCIDENT BENEFIT OPTION

 

ESSENTIAL PRIMARY PLUS | 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.

24-Hour emergency services are provided by ER24. In the event of a medical emergency or accident, you can call ER24 directly on 010 205 3044, press the ER24 push-to-call button in the Unity Health mobile app, or contact us.

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 61 or older and apply for cover on this option, you’ll pay a higher premium. If 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 onward, the 60 or younger premium will apply.

Children who are 20 years or younger pay child dependant premiums.

Children who are 21 years or older pay adult dependant premiums 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.

ENTRY AGE PRINCIPAL INSURED SPOUSE ADULT DEPENDANT CHILD DEPENDANT 
60 or younger R 175 R   95 R 95 R 39
61 or older R 220 R 140

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

24-Hour emergency services are provided by ER24. In the event of a medical emergency or accident, you can call ER24 directly on 010 205 3044, press the ER24 push-to-call button in the Unity Health mobile app, or contact us

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.

EMERGENCY & ACCIDENT BENEFIT OPTION PREMIUMS FOR INDIVIDUALS

If you’re 61 or older and apply for cover on this option, you’ll pay a higher premium. If 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 onward, the 60 or younger premium will apply.

Children who are 20 years or younger pay child dependant premiums.

Children who are 21 years or older pay adult dependant premiums 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.

 

 

PRINCIPAL INSURED
60 or younger R 175
61 or older R 220

 

 

SPOUSE
60 or younger R   95
61 or older R 140

 

 

ADULT DEPENDANT
60 or younger R 95
61 or older

 

 

CHILD DEPENDANT

 

60 or younger R 39
61 or older

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.

HOSPITAL CARE

Pre-authorisation is required for all HOSPITAL CARE benefits. Call us on 011 781 4488 for authorisation.

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.

If you need immediate medical treatment due to a medical emergency, we’ll cover the cost to transport you to the nearest private hospital and the cost to be admitted as an in-patient for stabilisation, limited to R 26 500 per person per event.

Only stabilisation is covered. Medical procedures that you need after being admitted to hospital, like a heart bypass, aren’t covered.

If you need further treatment after stabilisation, the cost to transfer you to a public hospital is covered, but any hospital costs thereafter will be for your own pocket.

ACCIDENT COVER

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.

If you need immediate medical treatment for physical injuries that you’ve sustained due to an accident, we’ll cover the cost to transport you to the nearest private hospital and the admission cost into hospital, limited to R 1 250 000 per person per event.

Your medical event must be pre-authorised as this will help with a smooth admission into hospital.

CASUALTY ACCIDENT COVER

For less serious accidents that still need immediate medical treatment, like a dog bite or an injury from working with factory machinery, you’ll be covered for treatment that you receive at your nearest private hospital’s emergency unit, limited to R 6 850 per person per event.

Your medical event must be pre-authorised.

MRI AND CT SCANS

If you’re admitted into hospital for physical injuries that you’ve sustained due to an accident, the cost of an MRI or CT scan will be covered, limited to R 18 000 per person per year.

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

PHYSIO AND OCCUPATIONAL THERAPY

To fully recover after an accident, you may need physical therapy.

If you were hospitalised due to an accident and need physical therapy after you’re discharged from hospital, the physiotherapist’s and occupational therapist’s fees will be covered limited to R 3 425 per person per year.

You must get pre-authorisation before starting therapy.

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

24-HOUR MEDICAL EMERGENCY SERVICES

ER24’s all-day, every-day national emergency contact centre will assist with the following medical emergency services:

  • 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 registerd spouse are covered for a benefit amount of R 25 000 per person if either one of you passes away due to an accident.

The benefit amounts are payable to your nominated beneficiaries, or to your respective estates if beneficiaries aren’t nominated.

Each registered child dependant is covered for a benefit amount of R 5 000, but only if death is due to a motor vehicle accident. The benefit amount for a child dependant is payable to the principal insured person on the policy.

WELLNESS BENEFIT

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.

Good to know: Skype counselling sessions can be arranged.
Face-to-face counselling isn’t covered and will be for your own pocket.

LIFESTYLE BENEFITS

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…

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.

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

These value-add benefits are 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 the Emergency & Accident Benefit Option.

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 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.      in-patient or out-patient hospital or casualty admissions where the medical events weren’t due to accidental events or emergencies, where applicable.
8.      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.
9.      MRI or CT scans, unless it’s due to accidental events.
10.   medical transportation if it’s not for emergency purposes.
11.   physiotherapy or occupational therapy for physical rehabilitation:
11.1  that’s not due to accidental events; or
11.2  that’s not provided within 3 months after you’ve been discharged from hospital.
12.    costs incurred for the voluntary stay at a private facility after stabilisation for a medical emergency.
13.    costs that, in the opinion of the Underwriting Manager’s clinical review team:
13.1  aren’t medically necessary or clinically appropriate;
13.2  don’t meet the healthcare needs of the insured person; or
13.3  aren’t consistent in type, frequency, or duration of treatment.
14.     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.
15.     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.
16.     external prosthetic devices or external medical items, like artificial limbs and wheelchairs.
17.      artificial insemination, infertility treatment or contraceptives.
18.      robotic surgery, specialised mechanical or computerised appliances, or equipment.
19.      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.
20.      riots, wars, political acts, public disorder, terrorism, civil commotions, labour disturbances, strikes, lock-out, or any attempted such acts.
21.      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.
22.      attempted suicide, intentional self-injury or deliberate exposure to exceptional danger unless it’s in an attempt to save a human life.
23.      events where the use of drugs, narcotics or alcohol are involved, including any illness or addiction caused by using such substances.
24.      participation in:
24.1  active military, police or police reservist duty;
24.2  aviation, other than as a passenger;
24.3  hazardous, competitive or professional sports or activities; or
24.4  any form of race or speed test, unless it’s on foot or involves any non-mechanically propelled vehicle, vessel, craft or aircraft.
25.     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.
26.      events that occur for which the actual damage is provided for by legislation, including contractual liability and consequential loss.
27.      non-disclosure of material information that is likely to affect the assessment or acceptance of risk.
28.      dual insurance where cover is provided by more than one health insurance policy through different insurers, or through the same insurer.

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