OUT-OF-HOSPITAL BENEFITS
TARIFF SHORTFALLS
Out-of-Hospital Benefits provide cover for tariff shortfalls on defined out-patient surgical procedures, treatments and medical expense shortfalls received as an out-patient, as well as cover for accidental casualty.
- Tariff Shortfalls
- Up to a maximum compensation limit of five times the Medical Scheme tariff fee to cover defined surgical procedures/treatment and medical expense shortfalls received as an out-patient.
- 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.
- Limited to certain diagnostic and medical procedures/treatment.
- Co-payments & Deductibles
- Includes MRI, CT and PET scans.
- Limited to certain diagnostic and medical procedures/treatment such as gastroscopies and colonoscopies; home births and dialysis treatment.
- Accidental Casualty Benefit
- Up to a maximum compensation limit of R15 000 per policy, per annum.
- Covers the actual cost of the services delivered in the casualty ward, less any amount paid by your Medical Scheme from risk pool benefits (i.e. not from medical savings).
- External Appliance Benefit
- Covers the purchase of external appliances up to a maximum of R2 000 per policy per annum.
- Limited to crutches, knee braces, arm slings and moon boots.
MAXIMUM COMPENSATION FOR ALL GAP COVER BENEFITS*
The total maximum Compensation Limit payable for all Core Benefits and Benefit Extender will be limited to R204 500 (two hundred and four thousand and 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 2024.
Terms & Conditions apply.
IMPORTANT TO NOTE:
- During the first 12 months of membership, a pre-existing condition waiting period applies.
- During the first 3 months of membership, a general waiting period applies.
- During the first 12 months of membership, a pregnancy waiting period applies.
Please note the 3 months general waiting period, 12 months pre-existing condition waiting period and 12 months pregnancy waiting period apply to an insured person from the time that such person's cover commences under the policy (to run concurrently if two or more waiting periods are applicable to an insured family member).
