A

Accidental Harm: Bodily injury caused by sudden violent, unintentional, external and physical means.

Administrator or Xelus: Xelus (Pty) Ltd (Registration No: 2008/019335/07), who is appointed to administer this Policy on behalf of the Mutual & Federal and is registered to do so in terms of the Short Term Insurance Act No. 53 of 1998.

Anniversary date: The anniversary date of your policy is January of every year, unless your Policy Schedule specifically states otherwise

B

Basic Dentistry: Is defined as the following dental Treatment: cleaning, extractions (including wisdom teeth), fillings, inlays, bonding, root canal Treatment, and Treatment for pain and abscess.

Balance Billing: A practice where a Medical Practitioner or other medical service provider charges a separately identifiable fee that is over and above the Tariff fee (or set of such fees) that relates to a Medical Procedure (or procedures), and is billed together on one statement or invoice and is not considered as a refundable Benefit by a Medical Scheme.

Benefit or Benefits: The Benefit amount payable to the Eligible Member in relation to an Insured Event, as calculated in terms of the Benefit Schedule, as defined.

C

Compensation Limit: The maximum amount for which you are covered for, as shown in your Policy Schedule.

Covered Events: The events that you are covered for. The Covered Events are shown in the Policy Section of your policy document.

D

Deductible or Co-payment: A defined, fixed amount specified in rands by the Insured’s medical scheme that is subtracted from the Insured’s Medical Scheme Benefit entitlement when undergoing defined Medical Procedures or Covered Events. For the purposes of this definition it explicitly excludes any Deductible or Co-payment that is specified by the Insured’s Medical Scheme as a percentage of costs and not a specified rand amount (this does not apply to the 20% Oncology co-payment).

Designated Service Provider or DSP: A medical service provider designated by a Medical Scheme as one of their preferred suppliers.

E

Eligible Child: A child, including a legally adopted child, or stepchild of an Eligible Member who is an eligible dependant on the Eligible Member’s Medical Scheme. In the event that the child reaches the age of 26 years the child will no longer be an Eligible Child and will therefore no longer be covered under this policy. When the Eligible Child turns 26 years of age, he/she may take up a new policy in their own capacity, within thirty (30) days of them reaching the aforementioned age, without any additional waiting periods or exclusions being applied. The above age limitation will not be applicable to a special needs child, as defined in this policy, who remains a beneficiary of the Eligible Member’s Medical Scheme.

Eligible Special Dependant: A dependant who is neither the Eligible Spouse nor an Eligible Child of the Eligible Member but who is an eligible dependant on the Eligible Member’s Medical Scheme and has been explicitly accepted by iWYZE Gap Cover for such cover under this policy. In the event that no such explicit acceptance is provided by iWYZE Gap Cover, such special dependants are not covered even though they are dependents of the Eligible Member’s Medical Scheme.

Eligible Spouse: A spouse means a person that you are married to in terms of South African law, a customary union, a religious union or that you have shared a home with as if you are a married couple for a minimum of 6 (six ) months prior to being covered under this policy. Your spouse must be registered as an active dependent on your medical aid to qualify for cover under this policy. Only one spouse can be covered under this policy. If you have more than one spouse registered as a dependent on your medical aid, we will take regard of the claim with the first spouse as the spouse covered under the policy.

F

Family: Means collectively the Eligible Member, his Eligible Spouse, eligible children and/or Eligible Special Dependents as defined in this Policy Document, who are also current and paid up beneficiaries of a registered Medical Scheme. When your child, your spouse or your Eligible special dependent is no longer registered as an active member on your medical aid, they will also no longer qualify for cover under this policy. Their cover will end at the same time as their cover under your medical aid ends.

H

Hospital: Any institution in the territory of the republic of South Africa which, in the opinion of iWYZE Gap Cover , meets all of the following criteria:

  • provides diagnostic and therapeutic facilities for surgical and medical diagnosis, Treatment and care of sick or injured persons by or under the supervision of medical practitioners;
  • provides 24 (twenty four) hour nursing services to sick or injured persons within the aforementioned facilities;
  • is not a day clinic or unattached operating theatre;
  • is not an institution that primarily cares for persons who are mentally retarded, blind, deaf, mute or in any other way physically handicapped;
  • is not a convalescent home or home for the elderly;
  • is not a place of rest or recuperation;
  • is not an institution that primarily treats people for drug addiction, alcoholism, eating disorders or any other form of addictive behaviour;
  • is not a health hydro or alternative therapy clinic or other similar establishment;
  • is not a step-down facility; and
  • is not an institution that primarily treats people for mental health disorders.

Hospital Episode: The period of time between admission to Hospital for an Insured until the time of discharge from Hospital of the same Insured person for the same Insured Event.

I

Illness: Any somatic disease or sickness which manifests in an Insured but is not a disease or sickness which is of such a nature as to be incapable of diagnosis by objective evidence or which even though capable of diagnosis by such evidence has not been diagnosed as such.

Insured /Insured Person/ You: Means the person who has cover under this insurance and it includes every person who qualifies for cover under this policy.

M

Medical Practitioner: A qualified Medical Practitioner, who is registered with the Health Professions Council of South Africa and is authorised to practice in the Republic of South Africa.

Medical Procedure: Any procedure defined under the National Health Reference Price List (NHRPL). It includes follow ups after the procedure by the Medical Practitioner that performed the procedure, while you are still admitted in hospital. In the event that any procedure or operation is not listed, iWYZE will calculate, at their sole discretion, an appropriate Benefit to be paid to the Eligible Member.

Medical Scheme: A Medical Scheme as registered under the Medical Schemes Act.

Medical Schemes Act: The Medical Schemes Act No. 131 of 1998 as amended and includes the regulations thereto.

Multiple: The percentage cover of the Tariff of the Benefit option of the Eligible Member’s Medical Scheme, which may differ for different Benefit categories of that Benefit option, and which constitutes a key component of the Benefit calculation as defined in the Benefit Schedule.

N

National Health Reference Price List or NHRPL: The Benefit Tariff set annually by the Department of Health as a guideline for charges by medical service providers or any replacement of the NHRPL affected by a change in law or statute or the generally accepted industry equivalent thereof.

P

Penalty: Any co-payment, deductible, exclusion or reduction, applied against the benefits of an Insured’s Medical Scheme, that would otherwise not have been applied had the authorisation rules of that medical scheme been adhered to or the benefits had been attained from the Designated Service Provider or Hospital Network of that Medical Scheme Benefit option.

Policy Exclusion: The list of services, conditions or events in the Policy which are excluded at all times from cover.

Policy Schedule: This sets out the type of cover you have bought, the people who are insured, the Period of Insurance, the amounts you are insured for, the benefits and the premium you must pay. Any changes to your policy will be shown in your Policy Schedule.

Policy Start Date: Cover will start on the first day of the calendar month for which the Premium has been paid by or on behalf of the Eligible Member, subject to all the terms and conditions of this Policy.

Premature Birth: Defined as the natural or surgically assisted birth of one or more infants by an Insured that occurs more than 41 days before the originally expected natural birth date. For the purpose of this clause, the originally expected natural birth date is accepted as being 40 weeks from date of conception and will be verified by the clinical records of the mother’s attending physician.

Premium or Premiums: The monthly amount payable by or on behalf of the Eligible Member to the Underwriter as defined in the Premium Schedule applicable to this Policy Document.

Principle/Eligible Member: The Insured who applied for cover under this Policy and who is a paid up member, including his Family as designated by him on inception of this Policy, and accepted by the Underwriter as eligible for participation in the insurance cover provided by this Policy.

S

Special Needs Child: Any child, including a legally adopted child or stepchild, of the Insured who, by virtue of either a physical or mental disability, is unable to financially support themselves and remains reliant on the Insured for support and care.

Split Billing: A practice where a Medical Practitioner or other medical service provider charges a separately identifiable fee that is over and above the Tariff fee (or set of such fees) that relates to a Medical Procedure (or procedures), and is billed separately from the Tariff fees on two or more statements or invoices, and is not considered as a refundable Benefit by a Medical Scheme.

T

Tariff: Either the NHRPL Tariff or a specific Tariff registered by a Medical Scheme to determine the rate at which its benefits are payable.

Trauma: Accidental Harm to an Insured Person that gives rise directly to an Insured Event.

Treatment: Any form of diagnosis, Treatment or care provided by a Medical Practitioner during a Covered Event for the purpose of treating or monitoring the medical condition of an Insured Person.

W

Waiting Periods: One or more time periods, commencing on the Inception Date, during which certain Benefits, as described in this Policy, are excluded. In the event of the death of the Eligible Member, any Benefit due will be compensated to the surviving Eligible Spouse, failing which the Benefit will be compensated to the eligible children (or their legal guardians in the event of them being minors) or failing any of the above, the Benefit will be compensated to the Eligible Member’s estate. No Benefit payable will carry interest. Any discount accrued by an Insured, against the amount owing by the Insured to any medical provider, will be factored into the calculation of the Benefits of this Policy.

We/us/our: Refers to iWYZE, underwritten by Mutual & Federal Insurance Company Ltd (Reg. No. 1970/006619/06).

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