OUT-OF-HOSPITAL BENEFITS

TARIFF SHORTFALLS

Shortfalls are the difference between what specialists charge and what your medical scheme pays for these services, often resulting in large shortfalls.

  • Up to 500% of medical scheme tariff fee to cover surgical procedures/treatment and medical expense shortfalls received as an out-patient.
  • Limited to certain diagnostic and medical procedures/treatment*.
CO-PAYMENTS & DEDUCTIBLES

A co-payment or deductible is a fixed, upfront fee, payable by the member on hospital admission and applies to procedures and certain diagnostic services.

  • Includes MRI, CT and PET scans.
  • Limited to certain diagnostic and medical procedures/treatment such as gastroscopies and colonoscopies.
ACCIDENTAL CASUALTY

If you have an accident and need emergency treatment at a hospital casualty ward, most medical schemes will not pay these costs from the hospital benefit. The accidental casualty benefit is for emergency out-patient treatment in a hospital casualty ward as a direct result of accidental harm, such as bodily injury caused by sudden violent, unintentional, external and physical means.

  • Up to a maximum benefit of R12 800 per incident.
  • 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

External appliances include and are limited to crutches, knee braces, arm slings and moon boots.

  • Covers the purchase of external appliances up to a maximum of R2 000 per policy per annum.

COMPENSATION

The total maximum compensation limit payable for all In-Hospital, Out-of-Hospital and Benefit Extender benefits will be limited to R150 000 (One hundred and fifty thousand rand) per family member per annum.



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