ESSENTIAL PRIMARY PLUS
EMERGENCY & ACCIDENT
BENEFIT OPTION
ESSENTIAL PRIMARY PLUS
EMERGENCY & ACCIDENT BENEFIT 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.
Your and your spouse’s parents may join as adult dependants. Adult dependant premiums will apply.
Other extended family members don’t qualify for cover.
In the event of an emergency, you may go to any private hospital. We’ll cover your medical event, subject to pre-authorisation.
PRE-AUTHORISATION
For casualty, stabilisation, hospital admission, MRI and CT scans, or physio and occupational therapy, pre-authorisation is required before benefits can be accessed.
ER24 is the network provider for 24-hour emergency services. In the event of a medical emergency or accident:
• Call 0861 366 006 and select option 1; or
• Press the ER24 push-to-call button in the Unity Health mobile app; or
• Call us on 011 781 4488.
Click here for a guide on how to download the Unity Health mobile app and the useful features it offers.
CLICK THE IMAGE OR BUTTON BELOW TO VIEW OR DOWNLOAD OUR BROCHURE.
HOSPITAL CARE
All HOSPITAL CARE benefits require pre-authorisation.
EMERGENCY COVER
What is a medical emergency? It’s an unexpected event or health condition, such as a heart attack or stroke, that can result in serious bodily impairment or death if you don’t receive immediate treatment.
If you require immediate treatment due to a medical emergency, the cost of transporting you to the nearest private hospital and stabilisation as an out-patient in the hospital’s emergency unit will
be covered.
This benefit covers the cost of stabilisation only, not the cost of admission or surgery.
If you need further medical treatment after being stabilised, the cost to transfer you to a public hospital will be covered, but the hospital admission and any other medical treatment will be for your pocket.
Limited to R 100 000 per person per event.
ACCIDENT COVER
What is an accidental event? It’s an unexpected event that requires immediate medical treatment due to physical injury caused by physical impact, such as a motor vehicle accident.
If you need immediate medical treatment for physical injuries sustained due to an accident, the cost of transporting you to the nearest private hospital and the admission will be covered.
Limited to R 1 600 000 per person per event.
Your medical event must be pre-authorised.
CASUALTY ACCIDENT COVER
For less severe accidents that still require immediate medical treatment, for example, a dog bite or falling off a ladder at home, you’ll be covered for treatment at your nearest private hospital’s emergency unit.
Limited to R 8 000 per person per event.
Your medical event must be pre-authorised.
MRI AND CT SCANS
The cost of an MRI or CT scan will be covered if you’re admitted to the hospital for physical injuries sustained due to an accident.
Limited to R 21 000 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’re hospitalised due to an accident and need physical therapy after discharge, the physiotherapist and occupational therapist’s fees will be covered.
Limited to R 4 000 per person per year.
You must get pre-authorisation before starting therapy.
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 spouse are covered for R 35 000 per person if either of you passes away due to an accident.
The benefit amounts are payable to your nominated beneficiaries or your respective estates if beneficiaries aren’t nominated.
Each child dependant is covered for R 10 000 if death is due to a motor vehicle accident. The benefit amount is payable to the principal insured or the principal insured’s estate if there’s no surviving principal insured.
WELLNESS BENEFIT
ESSENTIAL ASSISTANCE PROGRAMME (EAP)
Get telephonic advice and counselling services through Reality Wellness Group.
These services give you and your registered dependants virtual or telephonic counselling support by registered counsellors who follow clinical protocols and specific procedures.
Includes support for:
• financial guidance
• legal guidance
• HIV counselling and case management
• trauma counselling
Download the Reality Wellness Group mobile app from your app store to access holistic wellness services.
Virtual counselling sessions can be arranged but face-to-face counselling isn’t covered.
HOSPITAL CASH PLAN
HOSPITAL CASH PLAN (Add the HOSPITAL CASH PLAN for a small additional premium per person per month)
The HOSPITAL CASH PLAN can only be taken with the EMERGENCY & ACCIDENT BENEFIT OPTION. If you don’t take up the cash plan when applying, you can do so for the new benefit year beginning 1 January 2026.
A daily cash benefit is payable each day you’re hospitalised due to an accident if your hospital stay lasts at least 2 full days.
Limited to R 2 000 per day, to a maximum of R 30 000 per insured person per event.
This benefit doesn’t apply if hospitalisation is due to childbirth.
Your medical event must be an authorised event under the ACCIDENT COVER offered by your EMERGENCY & ACCIDENT BENEFIT OPTION.
Benefits payable for qualifying hospital admissions for your dependants will be paid to you. In the event of your death due to a qualifying hospital admission, the benefit amount will be paid to your nominated beneficiary or your estate if a beneficiary hasn’t been nominated.
A cash benefit is payable if you’re hospitalised for childbirth.
Limited to R 20 000 per hospital admission when the newborn or newborns reach 14 days of age.
This benefit applies to the admission only, not to the birth of each newborn.
Only the CHILDBIRTH PAYOUT BENEFIT is payable for childbirth, not the DAILY HOSPITAL PAYOUT BENEFIT.
Benefits payable for qualifying hospital admissions for your dependants will be paid to you. In the event of your death due to a qualifying hospital admission, the benefit amount will be paid to your nominated beneficiary or your estate if a beneficiary hasn’t been nominated.
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 or any dependant is 56 or older, you’ll pay a 56 or older premium. If proof of 15 credible years of medical aid membership or primary healthcare insurance cover from age 35 with no break in cover of 3 or more months is provided, a 55 or younger premium will apply.
Child dependant premiums apply to children 20 or younger, and adult dependant premiums to children between 21 and 25. From age 26, child dependants don’t qualify for cover under the same policy.
EMERGENCY & ACCIDENT BENEFIT OPTION PREMIUMS
| ENTRY AGE | PRINCIPAL INSURED | SPOUSE | ADULT DEPENDANT | CHILD DEPENDANT |
| 55 or younger | R 195 | R 119 | R 119 | R 56 |
| 56 or older | R 251 | R 175 | R 175 | — |
HOSPITAL CASH PLAN PREMIUMS
| ENTRY AGE | PRINCIPAL INSURED | SPOUSE | ADULT DEPENDANT | CHILD DEPENDANT |
| 55 or younger | R 90 | R 90 | R 90 | R 30 |
| 56 or older | R 120 | R 120 | R 120 | — |
EMERGENCY & ACCIDENT BENEFIT OPTION PREMIUMS
| ENTRY AGE | PRINCIPAL INSURED |
| 55 or younger | R 195 |
| 56 or older | R 251 |
| ENTRY AGE | SPOUSE |
| 55 or younger | R 119 |
| 56 or older | R 175 |
| ADULT DEPENDANT | |
| 55 or younger | R 119 |
| 56 or older | R 175 |
| CHILD DEPENDANT | |
| – | R 56 |
HOSPITAL CASH PLAN PREMIUMS
| ENTRY AGE | PRINCIPAL INSURED |
| 55 or younger | R 90 |
| 56 or older | R 120 |
| ENTRY AGE | SPOUSE |
| 55 or younger | R 90 |
| 56 or older | R 120 |
| ADULT DEPENDANT | |
| – | R 90 |
| CHILD DEPENDANT | |
| – | R 30 |
WAITING PERIODS AND GENERAL EXCLUSIONS
WAITING PERIODS
Waiting periods apply from your and your dependants’ cover start dates.
12 MONTH CHILDBIRTH PAYOUT BENEFIT WAITING PERIOD
You don’t have cover during this period for the CHILDBIRTH PAYOUT BENEFFIT under the HOSPITAL CASH PLAN.
EXCEPTION TO THE RULE
Waiting periods don’t apply to the EMERGENCY & ACCIDENT BENEFIT OPTION or DAILY HOSPITAL PAYOUT BENEFIT.
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:
- medical events that occurred before your cover start date.
- medical events during waiting periods, except for accidents and emergencies, where applicable.
- medical events when benefit limits have been reached.
- medical events your policy doesn’t cover or provide an appropriate benefit to claim from.
- medical events for which pre-authorisation or a healthcare provider referral hasn’t been obtained, where applicable.
- medical events when using healthcare or service providers not part of the provider network.
- in- or out-patient hospital and casualty admissions unrelated to an accident or emergency, where applicable.
- any pre-planned medical procedures, except if your policy offers a benefit.
- medical procedures performed when stabilised as an in-patient, except stabilisation required in an emergency.
- MRI or CT scans, except if due to an accident.
- medical transportation, except for emergencies.
- physiotherapy and occupational therapy, except if due to an accident, when treatment is provided within 3 months after discharge from the hospital.
- the voluntary stay at a private hospital facility after stabilisation for a medical emergency.
- 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. - failure to follow medical advice or adherence to prescribed treatment.
- revision surgeries following surgeries performed as a result of a claimable event.
- cosmetic surgery or surgery directly or indirectly caused by, related to or in consequence of cosmetic surgery.
- 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.
- robotic surgery, specialised mechanical or computerised appliances, or equipment.
- 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. - any claim, 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.
- 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.
- 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.
- any act (whether on behalf of an organisation, body, person, or group of persons) calculated or directed to overthrow or influence any state, government, provincial, local, or tribal authority with force or using fear, terrorism, or violence.
- 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. - 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.
- attempted suicide, suicide, intentional self-injury or deliberate exposure to exceptional danger, except if trying to save a human life.
- events where the use of drugs, narcotics or alcohol is involved, where the alcohol content in the blood exceeds the legal level permitted by law, including any illness or addiction caused by using such substances.
- 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 form of race or speed test, unless it’s on foot or involves any non-mechanically propelled vehicle, vessel, craft or aircraft. - 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.
- events that occur for which the actual damage is provided for by legislation, including contractual liability and consequential loss.
- non-disclosure of material information that is likely to affect the assessment or acceptance of risk.
- dual insurance where cover is provided by more than one health insurance policy through different insurers, or the same insurer.
- any activity specifically prohibited by law.
- the failure of any electricity grid. This is applicable to any loss, damage, cost, expense or liability of whatsoever nature.
