Discovery Essential Delta Saver medical aid plan: 2020

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Essential Delta Saver
2020 Costs:
Total Cost pm:

Main member:

R2,085

Adult:

R1,575

Child:

R837
Savings: R3,744 R2,832 R1,500



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IN HOSPITAL PROCEDURES:
Essential Delta Saver
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 100% 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, 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
Transplants:
  • Covered
Co-payments:
  • Defined procedures performed outside of day surgery network: R8,350
  • Scopes, in-hospital: R5,000 co-payment paid from day-to-day benefit
  • No co-payment if done in doctor's rooms
  • This applies to gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy
  • 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:
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):
Essential Delta Saver
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
General info:
  • Consider getting Primary Health Care (PHC) (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
GP consultations:
  • From day-to-day benefit unless PMB
  • GP in Premier Plus network: M =2 consults and M+ =4 consults if your savings are depleted. Face-to-face or video call.
  • See Primary Health Care benefit above
Childcare:
Specialists consultations:
  • From day-to-day benefit, unless PMB
  • See Primary Health Care benefit above
Pathology:
  • From day-to-day benefit, unless PMB
  • See Primary Health Care benefit above
General radiology:
  • From day-to-day benefit, unless PMB
  • See Primary Health Care benefit above
Specialised radiology:
  • From day-to-day benefit, unless PMB
Supplementary Services: (Physio, etc)
  • From day-to-day benefit, unless PMB



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MATERNITY BENEFITS:
Essential Delta Saver
Scheme Benefits Notes and Links:
Hospital stay:
  • 100% scheme rate for specialists
  • The Blue Plan gap cover will increase this to 500% scheme rate
Consultations:
    Discovery pays for:
  • 8 consults, paid by scheme
  • Nuchal translucency or Non-Invasive Prenatal Test, paid by scheme
  • Certain blood tests, paid by scheme
  • Five pre- or postnatal classes with registered nurse
  • One lactation consult
Scans:
    Discovery pays for:
  • 2 x ultrasound scans



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CANCER (ONCOLOGY):
Essential Delta Saver
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • Unlimited. After the first R200,000, a 20% co-payment applies for non-PMB cancers
  • All cancer-related treatments are covered at 100% scheme rate
  • Specialised medicine and technology: No benefit, unless PMB
  • Unlimited palliative care cover for approved care at home



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DENTISTRY:
Essential Delta Saver
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. This includes 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
Orthodontics:
  • See above
Maxillo Facial Surgery:
  • See above



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MEDICATION:
Essential Delta Saver
Scheme Benefits: Notes and Links:
Chronic:
  • Conditions covered:27 CDL conditions
  • Co-payment for use of non-formulary:
Acute (presrcibed) medication:
  • From day-to-day benefit
  • Consider getting Primary Health Care (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
Over-the-counter:
  • From day-to-day benefit
Birth Control:
  • From day-to-day benefit
On Discharge:
  • From day-to-day benefit
Biological:
  • No benefit, unless PMB level of care



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OPTOMETRY:
Essential Delta Saver
Scheme Benefits: Notes and Links:
Optometry:
Limit:From day-to-day benefit
Consult:n/a
Frames:n/a
Single lensesn/a
Bifocals:n/a
Multifocalsn/a
Contactsn/a
Refractive Surgery:n/a
Notes:
  • 20% discount on frames and lenses at a network optometrist



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    MENTAL HEALTH:
    Essential Delta Saver
    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, from day-to-day benefit
    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:
    Essential Delta Saver
    Scheme Benefits Notes and Links:
    General Appliances:
    • Cochlear implants: R223,700
    • Internal nerve stimulators: R153,600
    • Otherwise, from day-to-day benefit
    1.1. Hearing Aids:
    • From day-to-day benefit
    1.2. Wheelchairs:
    • From day-to-day benefit
    Dialysis:
    • Covered in full if you use network provider
    International Insurance:
    • Up to R5 million per person on each journey for emergency medical costs while outside South Africa
    • Emergency medical evacuations from certain sub-Saharan African countries back to South Africa
    Other:
    • Internal nerve stimulators: R147,300
    • DNA Analysis: paid in full from day-to-day benefit or 50% from above threshold
    • Second opinion from Cleveland Clinic for life-threatening and life-changing conditions. 50% co-payment



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    WELLNESS/PREVENTATIVE BENEFITS:
    Essential Delta Saver
    Scheme Benefits: Notes and Links:
    Flu vaccination:
    • Covered, for 65 yrs+
    Pneumonia vaccines:
    • To be confirmed
    Biometric Screening:
    • Covered
    Child Immunisation: TBC
    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:
    Essential Delta Saver
    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