Total annual limit
Subject to an Overall Annual Limit (OAL) of R210,580 per insured person.

Tariff shortfalls
We pay up to an additional 500% for shortfalls on doctors’ procedures performed in hospital. We also pay up to an additional 500% on doctors’ procedures performed out of hospital, but deemed to be in-hospital by the medical scheme and paid from risk.

Listed Procedures:
We pay a benefit equal to the cost of in-hospitalisation and associated medical expenses relating to one of the below-mentioned listed procedure, less the cover provided in terms of the insured’s medical scheme option. Annual limit of R80,000.

• In-hospital management of dentistry, limited to impacted teeth for minors under 18 years or reconstructive plastic surgery due to an accident during the period of cover
• Functional nasal surgery
• Surgery for oesophageal reflux and hiatus hernia
• Knee and shoulder surgery
• Back and neck treatment or surgery, joint replacements, including but not limited to hips, knees, shoulders, and elbows
• Cochlear implants, auditory brain implants, and internal nerve stimulators. This includes procedures, devices, and processors
• Bunionectomy
• Arthroscopy
• Removal of varicose veins
• Breast lumpectomy limited to the excision of the lump only and excluding any pathology and testing thereof
• Skin diseases including benign growths and lipomas
• Non-cancerous breast conditions

Co-payments / deductibles
We pay the defined
co-payment/deductible amount that medical aid schemes have specified for co-payments or deductibles. Annual limit of R10,000, limited to R5,000 per event.

Casualty Benefit
We pay when you have accidental trauma-related or crime-related injuries which require treatment in a hospital out-patients or casualty unit.
The limit is R10,000 per event.

Illness-related emergencies for infants and children under the age of 8 will be covered at any time of the day or night.

Illness-related emergencies for members 8 years and older will be covered between 6pm and 8am.

All illness-related emergencies are limited to R3,000 per event and R8,000 per family per annum.

Medical Aid Assist and GAP Premium Waiver
We pay a maximum amount of R2,500 per month for a period of 6 months to assist with medical aid premiums in the event of the death or permanent disability of the principal member. We will also provide free Network Plus Gap cover for a period of 12 months, provided that the insured member remains insured on the medical aid.

Consumables
We pay for shortfalls on medicine, materials, and appliances used during an in-hospital procedure or used by doctors during procedures performed in rooms that are deemed by the medical scheme to be ‘in hospital’. Annual limit of R3,000, limited to R500 per event.