Discovery Classic Delta Comprehensive: 2020

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Classic Delta Comprehensive
2020 Costs:
Total Cost pm:

Main member:

R5,362

Adult:

R5,077

Child:

R1,069
Savings: R16,080 R15,228 R3,204
Self Payment Gap:
R4,750 R5,602 R785
Above Threshold: No limit No limit No limit



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IN HOSPITAL PROCEDURES:
Classic Delta Comprehensive
Scheme Benefits: Notes and Links:
non-Network Specialists:
  • The Blue Plan gap cover will increase this to 500% scheme rate
network Specialists:
  • Full cover, for contracted specialists
  • The Blue Plan gap cover will increase this to 500% scheme rate
non-Network GPs:
  • Up to 200% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
network GPs:
  • Full cover, for contracted specialists
  • The Blue Plan gap cover will increase this to 500% scheme rate
Hospital Choice:
  • Choose a Delta Network
Penalty for using other hospital:
  • R7,650 if you voluntarily choose another hospital
Specialised Radiology:
  • If not related to admission or for conservative back or neck treatment, R3,175 co-payment from day-to-day benefit
Supplementary Services: (Physio, etc)
  • Covered in full for professionals with payment arrangement with Discovery
  • Otherwise, 200% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
Transplants:
  • Covered
Co-payments:
  • Scopes, in-hospital: R4,100 co-payment paid by you from day-to-day benefit or by your gap cover
  • This applies to gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy. No co-payment if done in doctor's rooms.
  • In-hospital dentistry: co-payment required for some admissions. See dentistry benefit for details
Alternatives to hospitals:
  • Administration of IV, iron treatments, steroids and immunoglobulins when a hospital admission is not required: covered
  • Care for venous ulcers, diabetic foot ulcers, pressure sores and other moderate to severe wounds for patients who do not require hospital admission: covered
  • Terminal care: R68,100 per person, per lifetime
  • Cancer: Unlimited palliative care cover for approved care at home
Casualty:
  • Accident and trauma (emergency) related costs covered
  • Both the Blue Plan and Red Plan gap cover will pay up to R20,000 per person for unpaid casualty costs in event of emergency
Other:
  • International Second Opinion: members can obtain second opinion from Cleveland Clinic, with a 50% co-payment
  • Overseas Treatment Benefit: R500,000 for treatment not available in South Africa, with 20% co-payment
  • Specialised medicine and technology: R200,000 per person with a 20% co-payment
  • Cochlear implants: R223,700
  • Internal Nerve stimulators: R153,600
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R157,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R157,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)



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All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Classic Delta Comprehensive
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Self Payment Gap:
R4,750 R5,602 R785
General info: AskAdam
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
Discovery Gap:
  • Additional R2,500-R20,000 for some outstanding costs not covered by scheme, related to hospital admissions
GP consultations:
  • From day-to-day benefit unless PMB
  • If in Self Payment Gap, GP consults and kid casualty visits covered by scheme, if using network provider
Childcare:
  • If in Self Payment gap, unlimited network GP visits and 2 kid casualty visits covered by scheme if using network providers
Specialists consultations:
  • From day-to-day benefit, unless PMB
  • 100% scheme rate unless Discovery has payment arrangement with specialist
Pathology:
  • From day-to-day benefit, unless PMB
General radiology:
  • From day-to-day benefit, unless PMB
Specialised radiology:
  • The first R3,175 from day-to-day benefit, balance paid by scheme
AskAdam Gap:
  • Co-payment benefit pays the co-paymentsfor MRI and CT scans
Discovery Gap:
  • No benefit, unless PMB
Supplementary Services: (Physio, etc)
  • From day-to-day benefits. Includes allied, therapeutic and psychology services
  • Main M1 M2 M3+
    R20,350 R27,650 R33,750 R39,100
  • For a defined list of conditions you get unlimited cover for biokineticists, acousticians, physiotherapists, occupational therapists, and speech and language therapists. Speak to Discovery directly



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MATERNITY BENEFITS:
Classic Delta Comprehensive
Scheme Benefits Notes and Links:
Hospital stay:
  • 200% scheme rate
  • Up to R1,880 for private ward
  • The Blue Plan gap cover will increase this to 500% scheme rate
Consultations:
    Discovery pays for:
  • 12 consults
  • Nuchal translucency or Non-Invasive Prenatal Test
  • Up to R5,000 for registered devices (breast pumps, etc) with 25% co-payment
  • Certain blood tests
  • Five pre- or postnatal classes with registered nurse
  • For two years after birth: two visits for baby with GP, Paediatrician or ENT; one six week post-birth consult with midwife, GP or gynae; one nutritional assessment; two mental health consults; one lactation consult
  • Antenatal classes: R1,750 per family
Scans:
    Discovery pays for:
  • 2 x ultrasound scans



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CANCER (ONCOLOGY):
Classic Delta Comprehensive
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • Unlimited, subject to sublimit below. After the first R400,000, a 20% co-payment applies for non-PMB cancers
  • All cancer-related treatments are covered at 100% scheme rate
  • Specialised medicine and technology, defined list: R200,000 per person with a 20% co-payment
  • Unlimited palliative care cover for approved care at home



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DENTISTRY:
Classic Delta Comprehensive
Scheme Benefits Notes and Links:
Standard Dentistry:
  • Standard dentistry: from day-to-day benefit
  • Consider getting Primary Health Care (medical insurance) that will cover you for a lot of out of hospital claims, including standard dentistry like scaling, polishing, fillings, extractions, root canals and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
Specialised Dentistry:
  • Specialised dentistry: from day-to-day benefit, limited to R32,750 per person
  • This limit includes claims for orthognathic surgery, dental appliances and their placements
In-Hospital Dentistry: In-hospital:
  • For severe dental and oral surgery, a defined list of procedures is included, with no upfront payment and no overall limit
  • Otherwise, you need to pay a portion of your account upfront:
    • If you are younger than 13, you pay R2,650 for admission to hospital, and R1,200 for admission to a day-clinic
    • If you are 13 and older, you pay R6,800 for admission to hospital, and R4,380 for admission to day-clinic
    • Balance of account is paid by scheme at200% scheme rate for anaesthetists and 100% scheme rate for other accounts.
Orthodontics:
  • See above
Maxillo Facial Surgery:
  • See above



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MEDICATION:
Classic Delta Comprehensive
Scheme Benefits: Notes and Links:
Chronic:
Acute (presrcibed) medication:
  • Schedule 3 and above
  • From day-to-day benefit, up to the limits below
  • If you are in the Self Payment Gap, Discovery will still pay for the medicine, up to the limits below
Main M1 M2 M3
R34,711 R40,750 R47,300 R53,950
Over-the-counter:
  • From day-to-day benefit
  • These do not add up to the annual threshold, and are not paid for from it
Birth Control:
On Discharge:
  • See "Acute Medicine" benefit
Biological:
  • For a defined list of latest treatments, limited to R200,000 per person, with a 20% co-payment



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OPTOMETRY:
Classic Delta Comprehensive
Scheme Benefits: Notes and Links:
Optometry:
Limit:R6,050 per person. Paid from day-to-day benefit.
Consult:from above limit
Frames:from above limit
Single lensesfrom above limit
Bifocals:from above limit
Multifocalsfrom above limit
Contactsfrom above limit
Refractive Surgery:from above limit
Notes:20% discount on frames and lenses at network optometrist



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MENTAL HEALTH:
Classic Delta Comprehensive
Scheme Benefits Notes and Links:
In-hospital:
  • Major affective disorders, anorexia and bulimia: 21 days for admissions or 15 out-of-hospital consultations
  • Acute stress disorder accompanied by recent significant trauma: 21 days for admissions or 12 out-of-hospital consultations
  • Other mental health admissions: 21 days in-hospital
  • Alcohol and drug rehab: 21 days in-hospital
  • All admissions are covered in full at a network facility, or at 80% scheme rate at a non-network facility
Out-of-hospital:
  • See above
  • Otherwise, paid from day-to-day benefit. Claims for psychologists and social workers fall into the supplementary benefit sub limit ie:
Main M1 M2 M3+
R20,350 R27,650 R33,750 R39,100
Trauma:
  • Offers out of hospital claims for recovery after traumatic events for rest of year, and year after that



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OTHER BENEFITS:
Classic Delta Comprehensive
Scheme Benefits Notes and Links:
General Appliances:
  • External appliances limited to R58,800 per family from day-to-day benefit
  • Cochlear implants: R223,700
1.1. Hearing Aids:
  • R24,700 per family paid from day-to-day benefit
1.2. Wheelchairs:
  • See "General Appliances" limit
Dialysis:
  • Covered in full if you use network provider
International Insurance:
  • Up to R5 million per person for emergency costs while travelling outside South Africa, for a period of 90 days. Excludes pre-existing conditions.
  • R500,000 per person for international treatment not available in South Africa, with 20% co-payment
Other:
  • Internal nerve stimulators: R147,300
  • Trauma recovery: out-of-hospital claims related to certain traumatic events paid until the end of the year following the event
  • DNA Analysis: paid in full from day-to-day benefit or 50% from above threshold
  • International Second Opinion: members can obtain second opinion from Cleveland Clinic, with a 50% co-payment



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WELLNESS/PREVENTATIVE BENEFITS:
Classic Delta Comprehensive
Scheme Benefits: Notes and Links:
Flu vaccination:
  • Covered, for 65 yrs+
Pneumonia vaccines:
  • To be confirmed
Biometric Screening:
  • Covered
Child Immunisation:
  • From day-to-day benefit
Pap Smear:
  • Covered, every 3 years
Mammogram:
  • Covered, every 2 years
  • If you qualify, you can get Breast MRI and once-off BRCA test for breast screening
PAS Test:
  • Covered
HIV Test:
  • Covered
Other:
  • Kids' assessment, including height, weight, head circumference and health and milestone tracking



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PROSTHETICS:
Classic Delta Comprehensive
Scheme Benefits: Notes and Links:
Overal Limit:
  • Shoulder joint prostheses: no limit, unless you use non-network supplier, in which case R41,700 limit applies
  • Major joints surgery: no limit, unless you use non-network supplier, in which case 80% scheme rate and R30,000 per prosthesis limit applies
  • Spinal surgery: no limit, unless you use non-network supplier, in which case R25,500 limit for first level and R51,000 for two or more levels. Limted to one procedure per person per year.
Sub-limits: .



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    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised