Exclusions: Note that all schemes have extensive exclusions. We've tried to list the major ones, but you must consult with your scheme to get the full list.
All treatments and procedures are subject to authorisation and protocols
All benefits are listed as an indication only. Please verify with your broker and scheme
Assume scheme pays all these costs, unless otherwise stated
Hospital stay:
100% scheme rate
Usually covered for 2 nights for natural birth, and 3 nights for C-sections. All newborns receive immediate full medical aid cover at birth, even if parents are on a waiting period.
Consultations:
GP, midwife, specialist: 9 consults
Specialist: Limited to 4 consults
Scans:
2 x 2D scans, paid by scheme
2 x haemoglobin tests
1 x blood group test
1 x VDRL test for syphillis
1 x HIV Elisa test
Note:
If you are pregnant and don't have medical aid, your pregnancy will most likely be excluded for new cover, but your baby will be covered from birth. Read more about pregnancy cover if you don’t have medical aid.
Assume scheme pays all these costs, unless otherwise stated
In-hospital:
21 days per person, including 6 in-hospital consults with psychiatrist
R42,000 per person per admission and R2,000 per day
Can be substituted with 10 consults in lieu of hospitalisation
Alcoholism/Drug Addiction:3 days withdrawal treatment plus 21 days rehab at an appropriate facility
Out-of-hospital:
PMBs: 10+ consults, paid by scheme
R9,525 per family for psychologists and psychiatrists for mental health disorders
Trauma:
Mental Health PMB conditions are covered for in and out of hospital treatment. For a full list see here.
Example of PMB condition: Acute stress disorder accompanied by recent significant trauma, including physical or sexual abuse. Treatment includes hospital admission for psychotherapy / counselling up to 3 days, or up to 12 outpatient psychotherapy / counselling contacts
