IN-HOSPITAL BENEFITS

TARIFF SHORTFALLS

Shortfalls are the difference between what specialists charge and what your medical scheme pays for these services.

  • Up to a maximum compensation limit of five times the medical scheme tariff fee if designated service providers are used.
  • Limited to a maximum compensation limit of one times the medical scheme tariff fee if a non-designated service provider is used on a medical aid plan driven by a designated service provider group network OR where treatment has been provided for maxillofacial or back and spinal surgery.
CO-PAYMENTS & DEDUCTIBLES

Your medical scheme requires you to pay a fixed, upfront fee called a co-payment or deductible, on certain procedures. This usually applies to defined surgical procedures, basic in-patient dentistry and diagnostic services and scopes.

  • Includes MRI, CT and PET scans if it occurs during a covered event.
  • Limited to certain diagnostic and medical procedures and treatment.
PENALTY CO-PAYMENT

If you do not have iWYZE Gap Cover, you will have to pay a penalty co-payment or deductible for the voluntary use of a hospital that is not part of a hospital network.

  • Up to a maximum compensation limit of R12 800 per one event, per family, per annum.
SHORTFALLS FROM SUB-LIMITS

Shortfalls from sub-limits occur when your medical scheme imposes a rand limit, known as a sub-limit, on certain treatment or prosthetic devices – without sufficient gap cover, you will need to pay in the difference.

  • Up to a maximum compensation limit of R44 000 per beneficiary, per event.
DENTAL BENEFITS
  • Up to a maximum compensation limit of R5 000 for tariff shortfall and R5 000 for co-payment per policy, per annum (limited to two events per annum) for limited basic and specialised dentistry as defined in the policy document.

MAXIMUM COMPENSATION FOR ALL GAP COVER BENEFITS*

The total maximum Compensation Limit payable for all Core Benefits and Benefit Extender will be limited to R164 500 (one hundred and sixty-four thousand, five hundred rand) per family member, per annum.

  • Includes cover for principal member and six dependants.

* Cover benefits, limits and maximum compensation limit applicable from 1 January 2020.

Terms & Conditions apply.




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