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Gap Cover & Health Insurance for Real People

HEALTH INSURANCE

ESSENTIAL PRIMARY PLUS

Our HEALTH INSURE product range, in partnership with UNITY HEALTH, offers comprehensive and essential cover through a national network of private healthcare providers.

Individuals aged 56 or older applying for cover on our DAY-TO-DAY BENEFIT OPTION or our DAY-TO-DAY, EMERGENCY AND ACCIDENT BENEFIT OPTION, and individuals aged 61 or older applying for cover on our EMERGENCY AND ACCIDENT BENEFIT OPTION will pay a higher premium as indicated in the 56+ and 61+ premium categories effective from the first day of cover, unless proof of medical aid or primary healthcare insurance cover for 15 or more years from the age of 35 can be provided.

WE COVER
  • You, your spouse and any child dependant of whom you are the parent or legal guardian.
  • Your child dependant aged 20 or younger at a child dependant premium.
  • Your child dependant aged 21 or older at an adult dependant premium if your dependant is financially
    dependent on you and proof is submitted every year. We accept proof of full-time studies from the
    educational facility or 3 months’ stamped copies of your dependant’s most recent bank statements.

This is not a medical aid and the cover is not the same as that of a medical aid. This policy is not a substitute for medical aid membership.

MONTHLY PREMIUMS

 

ENTRY AGE

MONTHLY PREMIUM
PRINCIPAL INSURED SPOUSE ADULT DEPENDANT
FINANCIALLY DEPENDENT 21+
CHILD DEPENDANT
20 OR YOUNGER
DAY-TO-DAY BENEFIT OPTION
55 or younger R 340 R 225 R 225 R 100
56+ R 501 R 386
EMERGENCY AND ACCIDENT BENEFIT OPTION
60 or younger R 145 R 80 R 80 R   32
61+ R 183 R 118
DAY-TO-DAY, EMERGENCY AND ACCIDENT BENEFIT OPTION
55 or younger R 435 R 310 R 310 R 120
56+ R 622 R 497

HEALTH INSURE

Our HEALTH INSURE product range, in partnership with UNITY HEALTH, offers comprehensive and essential cover through a national network of private healthcare providers.

BENEFIT OPTIONS

Choose between our DAY-TO-DAY BENEFIT OPTION that provides access to doctors, pharmacies, radiologists, pathologists, dentists, optometrists and your choice of gynaecologist, or our EMERGENCY AND ACCIDENT BENEFIT OPTION that covers you in the event of an emergency or accident at your nearest private hospital and the hospital’s casualty facility.

Need the best of both benefit options? Apply for cover on our DAY-TO-DAY, EMERGENCY AND ACCIDENT BENEFIT OPTION for complete peace of mind.

Whether you belong to a medical aid and apply for health insurance to top up your existing cover, or whether you apply for health insurance as your only cover, we have an option perfectly suited for you.

ESSENTIAL PRIMARY PLUS OPTION

Our ESSENTIAL PRIMARY PLUS OPTION is subject to open enrolment, community rating and cross- subsidisation which means that any individual may join at a premium that is specific to the Principal Insured, the Spouse, a Child and Adult Dependant.

DAY-TO-DAY

We take care of your day-to-day healthcare needs through Unity Health’s provider network that consists of more than 2 200 doctors, 2 500 dentists, 2 700 optometrists and various pharmacies, pathologists and radiologists.

DAY-TO-DAY BENEFITS

DAY-TO-DAY BENEFITS

CONSULTATION BENEFIT You may visit any Unity Health network doctor for an unlimited number of times.

When you visit your network doctor for 10 or more times, pre-authorisation will be required.

MEDICAL PROCEDURE BENEFIT Basic medical and surgical procedures can be performed in your network doctor’s rooms, such as a circumcision, stitching of a wound or applying a cast to a broken arm.
 

 

 

ACUTE MEDICATION BENEFIT

DISPENSING NETWORK DOCTOR

When you need medication for an acute condition or illness, such as a chest infection, sinusitis or flu, your dispensing network doctor can provide medication according to a formulary during one of your visits.

Acute medication that you receive in the rooms from your dispensing network doctor is unlimited.

NON-DISPENSING NETWORK DOCTOR

When your network doctor does not dispense medication from the rooms, you will be given a prescription to collect your medication from any Mediscor pharmacy, such as Clicks or Dis-Chem.

Acute medication that is prescribed by your non-dispensing network doctor is limited to R 3 000 per person per year.

 

 

CHRONIC MEDICATION BENEFIT

Your network doctor can help treat a chronic condition or disease.

We cover your chronic medication that your network doctor will prescribe according to a formulary to treat the following chronic conditions or diseases:

  • Asthma;
  • Hyperlipidemia;
  • Chronic Obstructive Pulmonary Disorder;
  • Hypertension;
  • Diabetes Type 1 & 2;
  • HIV/AIDS; and
  • Epilepsy;
  • Tuberculosis.
 

BLOOD TEST AND X-RAY BENEFIT

When you need a blood test, such as a cholesterol or glucose test or an x-ray, such as a black and white chest x-ray, your network doctor will refer you during one of your visits to the nearest pathology or radiology facility.

Your blood tests and x-rays are covered according to a list of approved tariff codes.

 

 

 

DENTAL CARE BENEFIT

Visit your network dentist for basic dental procedures such as a full mouth assessment, fillings or extractions, or when you need emergency dental treatment for an abscess or root canal.

Your network dentist can also provide urgent dental treatment when a physical injury causes loss or damage to your teeth.

All dental procedures are covered according to an approved list of tariff codes, limited to R1 150 per person per event and R3 500 per family per year.

Specialised dental procedures such as bridgework, crowns, dentures and orthodontic treatment are not covered.

 

 

 

EYE CARE BENEFIT

Your nearest PPN network optometrist can test your eyes and prescribe the lenses you need. We cover you for:

  • 1 eye test per person every year;
  • 1 standard frame to the value of R254 per person every 2 years; and
  • 1 pair of clear, standard spectacle lenses per person every 2 years.

When you choose optional extras, such as tinting or scratch resistant coatings, the cost will be for your own pocket.

 

 

MATERNITY CARE BENEFIT

As a soon-to-be-mom, you are covered for one-on-one consultations with a gynaecologist of your choice when you need advice during your pregnancy.

We will refund you for the cost of 2 maternity check-ups and 2 ultrasound scans per person per pregnancy per year, limited to R2 750 per family per year.

If you prefer, you may visit your network doctor for your ultrasound scans subject to the benefit limit provided under our MATERNITY CARE BENEFIT.

EMERGENCY AND ACCIDENT BENEFITS

You are covered for emergencies and accidents at your nearest private hospital and the hospital’s casualty facility.

When you are admitted into a private facility for a planned medical procedure, such as childbirth, cover does not apply.

EMERGENCY AND ACCIDENT BENEFITS

EMERGENCY AND ACCIDENT BENEFITS
OVERALL POLICY LIMIT (OPL) Each benefit has a rand amount limit that accumulates to an OVERALL POLICY LIMIT of

R 2 000 000 per policy per year.

 

 

 

 

 

 

 

 

HOSPITAL CARE BENEFIT

EMERGENCY COVER ACCIDENT COVER
You are covered for a medical emergency when you need treatment for an unexpected event

or health condition that can result in your death or serious bodily impairment if treatment is not received immediately, such as a heart attack or stroke.

We cover the transport cost to your nearest private hospital and the cost of stabilisation in the hospital’s emergency unit when you are admitted as an in-patient, limited to R 20 000 per person per event.

We do not cover medical procedures associated with your admission to hospital, such as a heart bypass.

If you need further treatment after stabilisation, we will cover the cost to transfer you to a public hospital. The cost of your admission to a public hospital and the medical treatment you receive will be for your own pocket.

You are covered at your nearest private hospital when you need medical treatment for physical injuries caused by accidental events, such as injuries from a motor vehicle accident, criminal act or from working with factory machinery.

We cover the cost of your hospital admission, including all associated healthcare providers’ costs during your stay in hospital, limited to

R 1 000 000 per person per event.

CASUALTY BENEFIT Medical treatment for a physical injury caused by a minor accidental event is covered at your nearest private hospital’s casualty facility, limited to R 5 250 per person per event.
 

MRI AND CT SCAN BENEFIT

When you are admitted to hospital as a result of an injury caused by an accident, the cost of your MRI or CT scan will be covered limited to R 15 000 per person per year.

Pre-authorisation will be required before you go for your scan.

 

 

REHABILITATION CARE BENEFIT

We cover the cost of your physiotherapist and occupational therapist when you need physical therapy for an injury caused by an accident for which you have been admitted to hospital.

Rehabilitative care must be provided by your therapist within 3 months from the date that you are discharged from hospital, limited to R 2 500 per person per year.

Pre-authorisation will be required before you visit your therapist.

 

 

 

 

24-HOUR MEDICAL EMERGENCY SERVICES BENEFIT

Our national emergency partner provides assistance when transportation or advice is needed in the event of a medical emergency.

You have access to our national 24-hour emergency contact centre for the following services:

  •  Telephonic medical advice;
  • Transport for a loved one to visit you in hospital should you be hospitalised outside of your residential city or town, limited to 1 event per policy per year;
  • Emergency transport services by air or road;
  • Ambulance transfers between hospitals;
  • Escorted return of your child dependant, aged 17 or younger, to a place of safety should they be present at the time of a medical emergency, limited to 1 event per year.
  • Repatriation of a loved one’s mortal remains should they be within the borders of South Africa, limited to R7500 per policy per year.

 

ACCIDENTAL DEATH BENEFIT

(Not subject to the Overall Policy Limit)

We cover you and your registered spouse in the event of your death due to an accident, limited to a benefit amount of R 10 000 per person.

ESSENTIAL WELNESS BENEFITS

Not only do we cover you for the cost of an annual health assessment, you also have access to our telephonic advice and counselling services.

ESSENTIAL WELLNESS BENEFITS
Our WELLNESS ASSESSMENT BENEFIT and PREVENTATIVE CARE BENEFIT are automatically included when you belong to our DAY-TO-DAY BENEFIT OPTION or our DAY-TO-DAY, EMERGENCY AND ACCIDENT BENEFIT OPTION.

Visit one of the registered nurse practitioners at your nearest Dis-Chem or Clicks pharmacy for your wellness assessment, preventative test or vaccination.

 

WELLNESS ASSESSMENT BENEFIT

You are covered for 1 wellness assessment per person per year that includes the following health checks:

  • Blood pressure;
  • Body Mass Index (BMI);
  • Cholesterol;
  • Waist circumference; and
  • Glucose levels;
  • HIV/AIDS, which includes counselling before and after testing.
 

 

 

PREVENTATIVE CARE BENEFIT

We cover the cost of the following preventative vaccinations and tests:

  • 1 Flu vaccination per person per year to be administered by the 31st of May;
  • 1 Pap smear every 3 years for insured persons 21 or older, or ask your network doctor about having this procedure done in the rooms during one of your visits;
  • 1 Pneumococcal vaccination every 5 years for insured persons 60 or older and individuals with a medically proven compromised immune system;
  • 1 Tetanus vaccination per person every 10 years; and
  • 1 Hepatitis A and B vaccination per person during the lifetime of the policy.
Our ESSENTIAL ASSISTANCE PROGRAMME is automatically included regardless of whether you belong to our DAY-TO-DAY BENEFIT OPTION, EMERGENCY AND ACCIDENT BENEFIT OPTION or our DAY-TO-DAY, EMERGENCY AND ACCIDENT BENEFIT OPTION.
 

ESSENTIAL ASSISTANCE PROGRAMME (EAP)

Our wellness partner, Reality Wellness Group, offers unlimited 24/7 telephonic advice and counselling services for:

  • Trauma counselling;
  • Legal advice; and
  • HIV counselling;
  • Financial advice.

When you need personal face-to-face counselling, the cost will be for your own pocket.

WAITING PERIODS, BENEFIT AND GENERAL EXCLUSIONS

 

YOUR HEALTH INSURE POLICY WAITING PERIODS

Waiting periods apply from each insured person’s cover start date before specific policy benefits can be claimed from.

2 MONTH GENERAL WAITING PERIOD

During the first 2 months of cover a general waiting period applies to our DAY-TO-DAY BENEFITS, WELLNESS ASSESSMENT BENEFIT and PREVENTATIVE CARE BENEFIT.

9 MONTH MATERNITY CARE WAITING PERIOD

During the first 9 months of cover a waiting period applies to our MATERNITY CARE BENEFIT.

12 MONTH CHRONIC MEDICATION WAITING PERIOD

During the first 12 months of cover a waiting period applies to our CHRONIC MEDICATION BENEFIT.

12 MONTH EYE CARE BENEFIT WAITING PERIOD

During the first 12 months of cover a waiting period applies to our EYE CARE BENEFIT.

EXCEPTIONS TO THE RULE

  • Waiting periods do not apply to our EMERGENCY AND ACCIDENT BENEFITS and

ESSENTIAL ASSISTANCE PROGRAMME (EAP).

GENERAL EXCLUSIONS APPLICABLE TO YOUR HEALTH INSURE POLICY

We do not cover service or healthcare providers’ accounts for related medical procedures and/or treatment, nor hospitalisation, illness, disease, loss, damage, death, bodily injury or liability for:

  1. Events you want to claim for, but you are not an insured person at the time of the event.
  2. Events that occur during your policy waiting period(s), unless you are claiming for an accidental event or a medical emergency where applicable.
  3. Events where a benefit or overall policy limit has been
  4. Events where your policy does not provide the appropriate benefit for you to claim
  5. Events where pre-authorisation was not requested or granted, or where an appropriate healthcare provider referral was not
  6. Events where the healthcare providers utilised do not form part of the provider network, unless a benefit specifically makes provision for
  7. Healthcare services that do not form part of our list of approved tariff codes or formularies, where
  8. In-patient or out-patient hospital or casualty admissions where the medical event was not due to an accidental event or an emergency, where
  9. Medical procedures performed as part of in-patient stabilisation except for the cost of stabilisation required in the event of an emergency, where the medical event is the result of a sudden, and at the time unexpected onset of a medical condition that requires immediate medical
  10. Physiotherapy or occupational therapy for physical rehabilitation:
    1. not due to an accidental event; or
    2. not provided within 3 months after discharge from hospital.
  11. MRI or CT scans not required due to an accidental
  12. Costs incurred for the voluntary stay at a private facility after stabilisation for a medical
  13. Reconstructive cosmetic or maxillo-facial surgery, including related medical conditions and procedures that do not form part of an authorised hospital event due to an accident.
  14. Obesity or its sequel, cosmetic surgery or surgery directly or indirectly caused by, related to or in consequence of cosmetic surgery, unless a benefit specifically makes provision for
  15. Eye care, other than an eye test, a frame and spectacle lenses covered under our EYE CARE
  16. External prosthetic devices or external medical items, such as artificial limbs and wheelchairs.
  17. Artificial insemination, infertility treatment and
  18. The use of robotic surgery, specialised mechanical or computerised appliances and equipment.
  19. Routine physical, diagnostic procedures or examination where there is no objective indication of impairment in your
  20. Riots, wars, political acts, public disorder, terrorism, civil commotions, labour disturbances, strikes, lock-out, or any attempted such
  21. A deliberate criminal or fraudulent act, or any illegal activity conducted by you or a member of your household which directly or indirectly results in loss, damage or
  22. Attempted suicide, intentional self-injury and deliberate exposure to exceptional danger except when you attempt to save a human
  23. Events where the use of drugs or alcohol is
  24. Participation in:
    1. Active military, police or police reservist duty;
    2. Aviation, other than as a passenger;
    3. Hazardous, competitive or professional sports or activities involving an official or practice, event, race or contest; and
    4. Any form of race or speed test, except on foot or involving any non-mechanically propelled vehicle, vessel, craft or
    5. Nuclear weapons material, ionising radiations or contamination by radioactivity from any nuclear fuel, nuclear waste or from the combustion of nuclear fuel that includes any self-sustaining process of nuclear
  25. Events that occur for which the actual damage is provided for by legislation, including contractual liability and consequential
  26. Non-disclosure of material information that is likely to affect the assessment or acceptance of
  27. Dual insurance where cover is provided by more than one health insurance policy through different insurers, or the same