Your Gap Cover and Health Insurance Provider · insured by constantia insurance company limited...

Your Gap Cover and Health Insurance ProviderINDIVIDUAL PRODUCT RANGE

CLIENT APPLICATION FORM SUBMISSIONSSubmitting your Client Application Form is as easy as 1, 2, 3.

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CLIENT QUERIES AND POLICY ADMINISTRATIONContact one of our Client Support Specialists to enquire about your policy status or benefits, or to amend your policy profile.

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EMPLOYER GROUP SCHEME ADMINISTRATIONOur team of Employer Group Scheme Specialists are available to assist with queries, updates or amendments to your employer group profile, employees’ details, tax invoices and billing statements.

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BROKER PORTFOLIO ADMINISTRATION From enquiries and amendments pertaining to your brokerage’s profile, to commission payments and queries, our team of Broker Portfolio Specialists are standing by to assist.

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CLIENT CLAIM SUBMISSIONS AND ADMINISTRATION From claim submissions to enquiring about the progress on your claim, contact one of our Claims Specialists for assistance or feedback.

STRATUM GAP COVER CLAIMS e [email protected] f 086 633 3761

STRATUM HEALTH INSURE CLAIMS e [email protected] f 011 706 5568

STRATUM BENEFITS (PTY) LTDREG NO.: 2003/018155/07

HEAD OFFICE367 Surrey Avenue, Block C & D, Ferndale, Randburg, 2194Suite 386, Private Bag X09, Weltevredenpark, 1715t 086 111 3499 / 010 593 0981 f 086 633 3761 e [email protected] w www.stratumbenefits.co.za

REGIONAL OFFICESCAPE TOWNC/O Lubbe & Langeberg Roads, Unit 4, Frazzitta Business Park, Durbanville, 7550 t 021 914 6985 f 086 459 6033DURBAN2 Hopedene Grove, Main House, Morningside, Durban, 4001 t 031 940 1918 f 086 541 7036

SATELLITE OFFICEPORT ELIZABETH10 Mendelssohn Avenue, Pari Park, Port Elizabeth, 6070t 041 366 1140 f 086 582 8361

STRATUM HEALTH INSUREt 011 781 4488 f 086 633 3761 e [email protected]

OPERATING HOURSMon - Thurs 8:00 - 16:30Fri 8:00 - 16:00Sat 8:00 - 13:00 For Stratum Health Insure clients

We are easy to locate and invite you to visit us for personal face-to-face service.

Our head office is based in Johannesburg, with regional offices in Cape Town and Durban and satellite offices in Bloemfontein and Port Elizabeth.

ENGAGE WITH US

Western Cape

Limpopo

MpumalangaGautengNorth West

Northern Cape

Free State KwaZulu-Natal

Eastern Cape

Johannesburg

Bloemfontein

Port ElizabethCape Town

Durban

BASE CO-EVOLUTION08 10

• GAP BENEFIT

• CO-PAYMENT BENEFIT

• CASUALTY BENEFIT

• TRAUMA COUNSELLING BENEFIT

• CANCER DIAGNOSIS BENEFIT

• ADDITIONAL BENEFIT- ACCIDENTAL DEATH BENEFIT

• GAP BENEFIT


• ADDITIONAL BENEFIT - GAP POLICY PREMIUM WAIVER BENEFIT

• GAP BENEFIT


• ONCOLOGY BENEFITS- ONCOLOGY BENEFIT- ONCOLOGY OPTIMISER BENEFIT- CANCER DIAGNOSIS BENEFIT

• SUB-LIMIT BENEFIT




• GAP BENEFIT



• CANCER DIAGNOSIS BENEFIT


EDGE200 COMPACT200

GAP COVER200 RANGE GAP COVER500 RANGE

04 06

ELITE ACCESS OPTIMISER ESSENTIAL PRIMARY PLUS CLAIMS EXAMPLES

GAP COVER PRODUCT RANGE OVERVIEW

THE CLEAR PRINT

12 16 23 15

18

26

• GAP BENEFIT


• ONCOLOGY BENEFITS- ONCOLOGY BENEFIT- ONCOLOGY OPTIMISER BENEFIT- CANCER DIAGNOSIS BENEFIT

• SUB-LIMIT BENEFIT



• REHABILITATION OPTIMISER BENEFIT

• PREVENTATIVE CARE BENEFIT

• ADDITIONAL BENEFITS - GAP POLICY PREMIUM AND MEDICAL

SCHEME CONTRIBUTION WAIVER BENEFITS- ACCIDENTAL DEATH BENEFIT

• ACCESS OPTIMISER BENEFIT

+ ADD OUR GAP BENEFIT


• DAY-TO-DAY BENEFITS ONLY

• EMERGENCY AND ACCIDENTAL BENEFITS ONLY

• DAY-TO-DAY AND EMERGENCY & ACCIDENTAL BENEFITS

• ESSENTIAL WELLNESS BENEFITS

HEALTH INSURE RANGE GENERAL

T’S & C’S APPLY | E&OEINSURED BY CONSTANTIA INSURANCE COMPANY LIMITED (FSP 31111) AND UNDERWRITTEN BY AMBLEDOWN FINANCIAL SERVICES (PTY) LTD (FSP 10287)THIS POLICY IS A NON-MEDICAL SCHEME PRODUCT, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP04

www.stratumbenefits.co.za

EDGE 200

GAP COVER FOR AN INDIVIDUAL WITH AN OVERALL POLICY LIMIT (OPL) OF R 150 000 PER YEAR

Our EDGE200 option has been innovatively designed to give you the best start when insuring yourself against unforeseen medical shortfalls. We cover you, as the only individual insured on this option, when your medical scheme does not pay your private healthcare fees in full, remove the anxiety of unforeseen expenses for a casualty event and cover your gap cover policy premium when life happens.

WE COVER• You, whether you are the main member or dependant on a

medical scheme option.• You, as the only individual insured on this option.

R 100R 180R 300

MONTHLY PREMIUM

18 - 27 *28 - 64 *65+ *

ENTRY AGES

SingleSingleSingle

* Limited to one insured individual per policy

T’S & C’S APPLY | E&OEINSURED BY CONSTANTIA INSURANCE COMPANY LIMITED (FSP 31111) AND UNDERWRITTEN BY AMBLEDOWN FINANCIAL SERVICES (PTY) LTD (FSP 10287)THIS POLICY IS A NON-MEDICAL SCHEME PRODUCT, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP 05


GAP

COVE

R200

|

EDGE

200

GAP BENEFITWHY WE COVER YOU

Our GAP BENEFIT leaves you feeling assured that when an in- or out-of-hospital medical procedure is necessary and your service provider, such as your doctor or specialist, charges a rate more than what your medical scheme pays, the unexpected difference you are liable for won’t leave you out of pocket.

WHEN WE COVER YOU

• You are covered when your service providers charge a rate more than what your medical scheme pays for medical procedures performed in hospital, doctors’ and specialists’ private rooms, day clinics and other registered facilities, provided your service providers’ accounts are paid from your medical scheme hospital benefit, also known as a risk or major medical benefit, and not from your medical scheme savings account or day-to-day benefit.

• You are covered for Prescribed Minimum Benefit (PMB) medical procedures.

WHAT WE COVER YOU FOR

Our GAP BENEFIT provides an additional 200% cover, when you become liable for the difference between what your service providers charge, and what your medical scheme pays from your medical scheme hospital benefit for account shortfalls related to the following:

• Doctors and specialists

• Dentistry and related procedures limited to R 3 000 per year

• Basic radiology

• Specialised radiology limited to MRI, CT and PET scans up to R 2 000 per year

• Pathology

• Physiotherapy

• Consumable items such as surgical gloves, bandages and gauze

• Medication provided as part of your in- or out-of-hospital event

CASUALTY BENEFITWHY WE COVER YOU

Our CASUALTY BENEFIT offers rich benefits to ensure that you not only receive the very best medical care, but also not having to worry about an unforeseen out of pocket expense for a casualty event.

WHEN WE COVER YOU

• You are covered at a registered medical facility in the event of an accident, when immediate treatment is required for physical injury resulting from an external force outside your body due to impact with someone or something.

• We will refund the cost of the casualty event to you when you become liable to pay out of your own pocket, or when your medical scheme pays the event from your medical scheme savings account.


Our CASUALTY BENEFIT covers the cost of your casualty event up to R 2 500 per year, for accounts related to the following:


• Basic and specialised radiology

• Pathology


• Medication provided as part of your casualty event at the registered medical facility

• Upfront casualty co-payments or facility fees

ADDITIONAL BENEFITGAP POLICY PREMIUM WAIVER BENEFIT

WHY WE COVER YOU

Our GAP POLICY PREMIUM WAIVER BENEFIT offers you the security of knowing that when you are faced with unexpected change resulting in financial difficulty, we have you covered.

WHEN AND WHAT WE COVER YOU FOR

• Our GAP POLICY PREMIUM WAIVER BENEFIT covers your Stratum Benefits policy premium for 12 months in the event of death, permanent disability or forced retrenchment of the Stratum Benefits policy premium payer.

• This benefit is not subject to the Overall Policy Limit (OPL).

Where a claim under our GAP BENEFIT is received for a condition, procedure, surgery, treatment or an investigation and any related accounts in respect of Adenoidectomy, Tonsillectomy, Myringotomy/Grommets, Cardiovascular procedures, Cataract removal, Dentistry, Hysterectomy (unless due to cancer diagnosis), Hernia repair, Joint replacement, MRI, CT and PET scans, Nasal and sinus surgery, Pregnancy and childbirth, Spinal procedures and Scopes within the first 10 months of cover, and is not deemed as pre-existing or accidental, 20% of the total claim amount will be payable.



COMPACT 200

GAP COVER FOR INDIVIDUALS WITH AN OVERALL POLICY LIMIT (OPL) OF R 150 000 PER PERSON PER YEAR



WHEN WE COVER YOU





• Doctors and specialists• Dentistry and related procedures limited to R 3 000 per policy per year• Basic radiology• Specialised radiology limited to MRI, CT and PET scans up to

R 2 000 per policy per year• Pathology• Physiotherapy• Consumable items such as surgical gloves, bandages and gauze• Medication provided as part of your in- or out-of-hospital event

CO-PAYMENT BENEFITWHY WE COVER YOU

Our CO-PAYMENT BENEFIT provides you with the peace of mind that when your medical scheme requires you to pay upfront costs, we have you covered.

WHEN WE COVER YOU

• You are covered when your medical scheme requires you to settle a fee, known as a co-payment, deductible or hospital admission fee, prior to undergoing certain in- and out-of-hospital medical procedures or specialised radiology scans.

• We will refund the co-payment, deductible or hospital admission fee which is either settled by you or deducted from your medical scheme savings account.


• Our CO-PAYMENT BENEFIT covers in- and out-of-hospital medical procedure related and specialised radiology scan co-payments, deductibles or hospital admission fees, represented as either a rand amount or a percentage and is limited to R 15 000 per policy per year.

Our COMPACT200 option has been conceptualised with medical scheme members in mind because when account shortfalls affect your financial wellbeing, we’ll absorb the impact. Complete peace of mind is offered by our comprehensive benefits that fill the gaps in your medical scheme cover. We cover you when your medical scheme does not pay your private healthcare fees in full, refund upfront co-payment costs and lend a helping hand when you need oncology treatment

WE COVERINDIVIDUALS 64 AND YOUNGER• We cover you and your spouse on one policy, even if you belong to different

medical schemes or medical scheme options, including all dependants registered on your or your spouse’s medical scheme option.

INDIVIDUALS 65 AND OLDER• We cover you and your spouse on one policy, even if you belong to different

medical schemes or medical scheme options, or you and one other dependant registered on your medical scheme option.

• Where either one, or both individuals are 65 and older the 65+ premium will apply, limited to two insured individuals per policy.

R 180 R 210R 350

MONTHLY PREMIUM

64 and younger65+ *

FamilyFamilySingle or

Single

* Limited to two insured individuals per policy

ENTRY AGES



GAP

COVE

R200

|

COM

PACT

200

ONCOLOGY BENEFITSWHY WE COVER YOU

Our ONCOLOGY BENEFITS alleviate the financial pressure that is not conducive to an environment of healing, by offering you superior and unique benefits for your necessary oncology treatment.


ONCOLOGY BENEFIT

• You are covered when your medical scheme only pays a portion towards your approved oncology treatment such as radiotherapy, chemotherapy, basic and specialised radiology, pathology, specialist consultations, registered oncology facility fees, biological or specialised medication etc. The difference you are liable for may be referred to as a co-payment by certain medical schemes, or may reflect as a rand amount where your service provider charges a rate more than what your medical scheme pays.

• Our ONCOLOGY BENEFIT covers you when your medical scheme only pays a portion towards your service providers’ accounts.

ONCOLOGY OPTIMISER BENEFIT

• You are covered when your medical scheme provides you with an oncology benefit but applies a rand amount limit from which you can claim per year. Once this rand amount limit is reached, you will be liable to pay all treatment costs thereafter.

• Our ONCOLOGY OPTIMISER BENEFIT covers your oncology treatment costs when your medical scheme no longer does and is limited to R 50 000 per person per year.

CANCER DIAGNOSIS BENEFIT

• Our CANCER DIAGNOSIS BENEFIT provides a once-off payment of R 15 000 when you are diagnosed with cancer for the first time and the diagnosis aligns to specific qualifying criteria.


SUB-LIMIT BENEFITWHY WE COVER YOU

Our SUB-LIMIT BENEFIT affords you the opportunity to ensure that your health and recovery remain a priority, when your medical scheme applies a rand amount limit to your internal prostheses benefit, leaving you liable to pay a portion of the cost.

WHEN WE COVER YOU

• You are covered when your medical scheme provides you with a rand amount limit, known as a sub-limit or annual limit, from which you can claim for an internal prosthesis but the device costs more than the amount your medical scheme pays.


• Our SUB-LIMIT BENEFIT provides cover when you become liable to settle a portion of your internal prosthesis provider’s account, up to R 15 000 per event with a maximum of R 30 000 per person per year.


Our CASUALTY BENEFIT offers rich benefits to ensure that you not only receive the very best medical care, but also not having to worry about an unforeseen out of pocket expense for a casualty event.

WHEN WE COVER YOU




Our CASUALTY BENEFIT covers the cost of your casualty event up to R 5 000 per policy per year, for accounts related to the following:

• Doctors and specialists• Basic and specialised radiology • Pathology• Consumable items such as surgical gloves, bandages and gauze• Medication provided as part of your casualty event at the registered

medical facility• Upfront casualty co-payments or facility fees

TRAUMA COUNSELLING BENEFIT

WHY WE COVER YOU

Our TRAUMA COUNSELLING BENEFIT ensures you receive the support you need, when circumstances outside of your control alter the course of your life.

WHEN WE COVER YOU

• You are covered when you have witnessed, or are directly affected by an act of physical violence or an accident resulting in serious bodily injury or death.

• You are also covered when you are diagnosed with a dread disease, or are affected by a loved one’s diagnosis of a dread disease or death.

• We will refund the cost of the registered counsellor’s, clinical psychologist’s or psychiatrist’s consultation fee when you become liable to pay out of your own pocket, or when your medical scheme pays the fees from your medical scheme savings account.


• Our TRAUMA COUNSELLING BENEFIT covers your consultation fees up to R 5 000 per policy per year.

ADDITIONAL BENEFITACCIDENTAL DEATH BENEFIT

WHY WE COVER YOU

Our ACCIDENTAL DEATH BENEFIT offers you and your loved ones the security of knowing that when you are faced with unexpected change resulting in financial difficulty, we have you covered.


• Our ACCIDENTAL DEATH BENEFIT provides a payment of R 15 000 in the event of the accidental death of the principal insured or spouse and R 5 000 for the accidental death of a dependant.


Where a claim under our GAP BENEFIT, CO-PAYMENT BENEFIT or SUB-LIMIT BENEFIT is received for a condition, procedure, surgery, treatment or an investigation and any related accounts in respect of Adenoidectomy, Tonsillectomy, Myringotomy/Grommets, Cardiovascular procedures, Cataract removal, Dentistry, Hysterectomy (unless due to cancer diagnosis), Hernia repair, Joint replacement, MRI, CT and PET scans, Nasal and sinus surgery, Pregnancy and childbirth, Spinal procedures and Scopes within the first 10 months of cover, and is not deemed as pre-existing or accidental, 20% of the total claim amount will be payable.



BASE




WHEN WE COVER YOU






• Dentistry and related procedures limited to R 3 000 per policy per year

• Basic radiology

• Specialised radiology limited to MRI, CT and PET scans up to R 2 000 per policy per year

• Pathology

• Physiotherapy



Our BASE option provides real cover with real benefits when your medical scheme does not pay your private healthcare fees in full, when the unforeseen expense of a casualty event causes anxiety and lends emotional and financial support when circumstances outside of your control alter the course of your life.

R 180 R 205R 350

MONTHLY PREMIUM

64 and younger65+ *


Single






ENTRY AGES

*Limited to two insured individuals per policy



GAP

COVE

R500

|

BAS

E


Our CASUALTY BENEFIT offers you rich benefits to ensure that you not only receive the very best medical care, but also not having to worry about an unforeseen out of pocket expense for a casualty event.

WHEN WE COVER YOU





• Doctor or specialist consultations


• Pathology




TRAUMA COUNSELLING BENEFIT WHY WE COVER YOU

Our TRAUMA COUNSELLING BENEFIT ensures you receive the support you need, when circumstances outside of your control alter the course of your life.

WHEN WE COVER YOU






CANCER DIAGNOSIS BENEFIT WHY WE COVER YOU

Our CANCER DIAGNOSIS BENEFIT lends a helping hand by offering a humble gesture that assists you on the road to recovery.





WHY WE COVER YOU

Our ACCIDENTAL DEATH BENEFIT offers you and your spouse the security of knowing that when you are faced with unexpected change due to the loss of a loved one, we have you covered.


• Our ACCIDENTAL DEATH BENEFIT provides a payment of R 6 000 in the event of the accidental death of the principal insured or spouse.





CO-EVOLUTION


Our CO-EVOLUTION option has been expertly combined to provide just the right benefits when unforeseen medical expenses occur. From covering the gap that exists when your medical scheme does not pay your private healthcare fees in full, to benefits for co-payments, casualty events, trauma counselling, cancer diagnosis and accidental death, you can rest assured that we have you covered.

R 200 R 250R 400

MONTHLY PREMIUM

64 and younger65+ *


Single






ENTRY AGES




GAP

COVE

R500

|

CO

-EVO

LUTI

ON CO-PAYMENT BENEFIT

WHY WE COVER YOUOur CO-PAYMENT BENEFIT provides you with the peace of mind that when your medical scheme requires you to pay upfront costs, we have you covered.

WHEN WE COVER YOU• You are covered when your medical scheme requires you to settle a

fee, known as a co-payment, deductible or hospital admission fee, prior to undergoing certain in- and out-of-hospital medical procedures or specialised radiology scans.

• We will refund the co-payment, deductible or hospital admission fee which is either settled by you or deducted from your medical scheme savings account.

WHAT WE COVER YOU FOR• Our CO-PAYMENT BENEFIT covers in- and out-of-hospital medical

procedure related and specialised radiology scan co-payments, deductibles or hospital admission fees, represented as either a rand amount or a percentage and is limited to R 50 000 per policy per year.

CASUALTY BENEFITWHY WE COVER YOUOur CASUALTY BENEFIT offers you rich benefits to ensure that you not only receive the very best medical care, but also not having to worry about an unforeseen out of pocket expense for a casualty event.

WHEN WE COVER YOU• You are covered at a registered medical facility in the event of an

accident, when immediate treatment is required for physical injury resulting from an external force outside your body due to impact with someone or something.


WHAT WE COVER YOU FOROur CASUALTY BENEFIT covers the cost of your casualty event up to R 7 000 per policy per year, for accounts related to the following:

• Doctor or specialist consultations• Basic and specialised radiology • Pathology• Consumable items such as surgical gloves, bandages and gauze• Medication provided as part of your casualty event at the registered

medical facility• Upfront casualty co-payments or facility fees

TRAUMA COUNSELLING BENEFIT WHY WE COVER YOU

Our TRAUMA COUNSELLING BENEFIT ensures you receive the support you need and deserve, when circumstances outside of your control alter the course of your life.

WHEN WE COVER YOU







WHY WE COVER YOUOur CANCER DIAGNOSIS BENEFIT lends a helping hand by offering a humble gesture that assists you on the road to recovery.

WHEN AND WHAT WE COVER YOU FOR• Our CANCER DIAGNOSIS BENEFIT provides a once-off payment

of R 5 000 when you are diagnosed with cancer for the first time and the diagnosis aligns to specific qualifying criteria.



WHY WE COVER YOUOur ACCIDENTAL DEATH BENEFIT offers you and your spouse the security of knowing that when you are faced with unexpected change due to the loss of a loved one, we have you covered.

WHEN AND WHAT WE COVER YOU FOR• Our ACCIDENTAL DEATH BENEFIT provides a payment of R 7 000

in the event of the accidental death of the principal insured or spouse.• This benefit is not subject to the Overall Policy Limit (OPL).



WHEN WE COVER YOU







• Basic radiology


• Pathology

• Physiotherapy



Where a claim under our GAP BENEFIT or CO-PAYMENT BENEFIT is received for a condition, procedure, surgery, treatment or an investigation and any related accounts in respect of Adenoidectomy, Tonsillectomy, Myringotomy/Grommets, Cardiovascular procedures, Cataract removal, Dentistry, Hysterectomy (unless due to cancer diagnosis), Hernia repair, Joint replacement, MRI, CT and PET scans, Nasal and sinus surgery, Pregnancy and childbirth, Spinal procedures and Scopes within the first 10 months of cover, and is not deemed as pre-existing or accidental, 20% of the total claim amount will be payable.



GAP BENEFITWHY WE COVER YOUOur GAP BENEFIT leaves you feeling assured that when an in- or out-of-hospital medical procedure is necessary and your service provider, such as your doctor or specialist, charges a rate more than what your medical scheme pays, the unexpected difference you are liable for won’t leave you out of pocket.

WHEN WE COVER YOU• You are covered when your service providers charge a rate more than

what your medical scheme pays for medical procedures performed in hospital, doctors’ and specialists’ private rooms, day clinics and other registered facilities, provided your service providers’ accounts are paid from your medical scheme hospital benefit, also known as a risk or major medical benefit, and not from your medical scheme savings account or day-to-day benefit.


WHAT WE COVER YOU FOROur GAP BENEFIT provides an additional 500% cover, when you become liable for the difference between what your service providers charge, and what your medical scheme pays from your medical scheme hospital benefit for account shortfalls related to the following:

• Doctors and specialists• Dentistry and related procedures limited to R 5 000 per policy per year• Basic radiology• Specialised radiology limited to MRI, CT and PET scans up to

R 2 000 per policy per year• Pathology• Physiotherapy• Consumable items such as surgical gloves, bandages and gauze• Medication provided as part of your in- or out-of-hospital event

ELITE


Our ELITE option has been thoughtfully created with a clear vision to provide elite benefits that offer best-in-class cover, to ensure complete peace of mind knowing we have you covered. This option is perfectly suited for individuals who don’t compromise on cover. We don’t.

R 295 R 355R 575

MONTHLY PREMIUM

64 and younger65+ *


Single






ENTRY AGES




CO-PAYMENT BENEFIT WHY WE COVER YOUOur CO-PAYMENT BENEFIT provides you with the peace of mind that when your medical scheme requires you to pay upfront costs, we have you covered.

WHEN WE COVER YOU• You are covered when your medical scheme requires you to settle a

fee, known as a co-payment, deductible or hospital admission fee, prior to undergoing certain in- and out-of-hospital medical procedures or specialised radiology scans.

• We will refund the co-payment, deductible or hospital admission fee, which is either settled by you or deducted from your medical scheme savings account.

WHAT WE COVER YOU FOR• Our CO-PAYMENT BENEFIT covers in- and out-of-hospital medical

procedure related and specialised radiology scan co-payments, deductibles or hospital admission fees, represented as either a rand amount or a percentage.

• You are also covered for 1 co-payment up to an amount of R 8 500 per policy per year, for the voluntary use of a hospital or day clinic outside your medical scheme’s designated network.

GAP

COVE

R500

|

ELI

TE

ONCOLOGY BENEFITSWHY WE COVER YOU

Our ONCOLOGY BENEFITS alleviate the financial pressure that is not conducive to an environment of healing, by offering you superior and unique benefits for your necessary oncology treatment.


ONCOLOGY BENEFIT

• You are covered when your medical scheme only pays a portion towards your approved oncology treatment such as radiotherapy, chemotherapy, basic and specialised radiology, pathology, specialist consultations, registered oncology facility fees, biological or specialised medication etc. The difference you are liable for may be referred to as a co-payment by certain medical schemes, or may reflect as a rand amount where your service provider charges a rate more than what your medical scheme pays.

• Our ONCOLOGY BENEFIT covers you when your medical scheme only pays a portion towards your service providers’ accounts.

ONCOLOGY OPTIMISER BENEFIT

• You are covered when your medical scheme provides you with an oncology benefit but applies a rand amount limit from which you can claim per year. Once this rand amount limit is reached, you will be liable to pay all treatment costs thereafter.

• Our ONCOLOGY OPTIMISER BENEFIT covers your oncology treatment costs when your medical scheme no longer does.




SUB-LIMIT BENEFITWHY WE COVER YOU

Our SUB-LIMIT BENEFIT affords you the opportunity to ensure that your health and recovery remain a priority, when your medical scheme applies a rand amount limit to specific service providers’ accounts, leaving you liable to pay a portion of, or the full amount of the account.

WHEN WE COVER YOU

• You are covered when your medical scheme provides you with a rand amount limit, known as a sub-limit or annual limit, from which you can claim for internal prostheses, non-PMB day procedures, renal dialysis and MRI & CT scans but the device, procedure, treatment or scan costs more than the amount your medical scheme pays.

• You are also covered when your medical scheme provides you with a MRI & CT scan benefit but applies a rand amount limit, known as a sub-limit or annual limit, from which you can claim every year. Once this rand amount limit is reached, you will be liable to pay all costs thereafter.


• Our SUB-LIMIT BENEFIT provides cover when you become liable to settle a portion of your internal prosthesis provider’s account, or the service providers’ accounts relating to your non-PMB day procedure or renal dialysis treatment, up to R 30 000 per event with a maximum of R 60 000 per person per year.

• You will also be covered for a total number of 2 MRI or CT scans up to an amount of R 2 500 per scan per policy per year, when you become liable to settle a portion of, or the full amount of your service provider’s account.

Where a claim under our GAP BENEFIT, CO-PAYMENT BENEFIT or SUB-LIMIT BENEFIT is received for a condition, procedure, surgery, treatment or an investigation and any related accounts in respect of Adenoidectomy, Tonsillectomy, Myringotomy/Grommets, Cardiovascular procedures, Cataract removal, Dentistry, Hysterectomy (unless due to cancer diagnosis), Hernia repair, Joint replacement, MRI, CT and PET scans, Nasal and sinus surgery, Pregnancy and childbirth, Spinal procedures and Scopes within the first 10 months of cover, and is not deemed as pre-existing or accidental, 20% of the total claim amount will be payable, where applicable.



GAP

COVE

R500

|

ELI

TE C

ON

TIN

UED


Our CASUALTY BENEFIT offers you rich benefits to ensure that you not only receive the very best medical care, but also not having to worry about an unforeseen out of pocket expense for a casualty event.

WHEN WE COVER YOU





• Doctor or specialist consultations


• Pathology




TRAUMA COUNSELLING BENEFIT WHY WE COVER YOUOur TRAUMA COUNSELLING BENEFIT ensures you receive the support you need and deserve, when circumstances outside of your control alter the course of your life.

WHEN WE COVER YOU• You are covered when you have witnessed, or are directly affected by

an act of physical violence or an accident resulting in serious bodily injury or death.



WHAT WE COVER YOU FOR• Our TRAUMA COUNSELLING BENEFIT covers your consultation

fees up to R 10 000 per policy per year.

REHABILITATION OPTIMISER BENEFIT WHY WE COVER YOU

Our REHABILITATION OPTIMISER BENEFIT helps to get your life back on course, when you need physical rehabilitative care and access to skilled therapists in the event of an unforeseen accident.

WHEN WE COVER YOU

• You are covered when your medical scheme provides you with a rehabilitation benefit for accidental events, but applies a rand amount limit or a limit to the number of days you may be admitted, from which you can claim per year. Once these limits are reached, you will be liable to pay all treatment costs thereafter.


• Our REHABILITATION OPTIMISER BENEFIT covers your rehabilitation treatment provided by on-site therapists as well as your stay at a registered sub-acute or step-down facility, when your medical scheme no longer does and is limited to R 10 000 per person per year.

PREVENTATIVE CARE BENEFITWHY WE COVER YOUOur PREVENTATIVE CARE BENEFIT has been caringly put together to provide you the opportunity to undergo specific preventative screening tests when you are concerned about your health and wellbeing.

WHEN WE COVER YOU

• You are covered when you undergo a Pap smear, prostate screening (PSA test) or a full blood count (FBC test) to help diagnose certain cancers.

• We will refund the cost of your service provider’s consultation fee and the cost of your test when you become liable to pay out of your own pocket, or when your medical scheme pays the cost from your medical scheme savings account.

WHAT WE COVER YOU FOR• Our PREVENTATIVE CARE BENEFIT covers your consultation fees

or the cost of the tests up to an amount of R 500 per policy per year.

ADDITIONAL BENEFITS WHY WE COVER YOU

Our ADDITIONAL BENEFITS offer you and your loved ones the security of knowing that when you are faced with unexpected change resulting in financial difficulty, your cover will remain unchanged because we have you covered.


• Our GAP POLICY PREMIUM WAIVER BENEFIT covers your Stratum Benefits policy premium for 12 months in the event of death, permanent disability or forced retrenchment of the Stratum Benefits policy premium payer.

• Our MEDICAL SCHEME CONTRIBUTION WAIVER BENEFIT covers your medical scheme contribution for 6 months to a maximum of R 4 500 per month, in the event of death or permanent disability of the medical scheme contribution payer.

• Our ACCIDENTAL DEATH BENEFIT provides a payment of R 25 000 in the event of the accidental death of the principal insured or spouse and R 5 000 for the accidental death of a dependant.

• These benefits are not subject to the Overall Policy Limit (OPL).

15T’S & C’S APPLY | E&OEINSURED BY CONSTANTIA INSURANCE COMPANY LIMITED (FSP 31111) AND UNDERWRITTEN BY AMBLEDOWN FINANCIAL SERVICES (PTY) LTD (FSP 10287)


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Below are two examples of how our 500% GAP BENEFIT ensures your medical shortfalls are covered.

CLAIM FOR CHILDBIRTH UNDER OUR GAP BENEFITSERVICE PROVIDERS SERVICE PROVIDERS

CHARGEDYOUR MEDICAL SCHEME PAID

GAP BENEFIT WILL COVER

YOU ARE LIABLE FOR

Gynaecologist R 11 000.00 R 4 922.10 R 6 077.90 R 0

Anaesthetist R 6 398.66 R 1 871.02 R 4 527.64 R 0

Total R 17 398.66 R 6 793.12 R 10 605.54 R 0

CLAIM FOR COLONOSCOPY UNDER OUR GAP BENEFITSERVICE PROVIDERS SERVICE PROVIDERS


GAP BENEFIT WILL COVER

YOU ARE LIABLE FOR

Specialist R 9 144.60 R 3 943.94 R 5 200.66 R 0

Anaesthetist R 2 293.70 R 1 185.80 R 1 107.90 R 0

Total R 11 438.30 R 5 129.74 R 6 308.56 R 0

Our CASUALTY BENEFIT provides a rand amount limit from which you can claim for costs at a registered medical facility for accidental events, when immediate treatment is required for physical injury. When your medical scheme does not provide you with cover or pays a casualty event from your available medical scheme savings account, you can rest assured that we have you covered.

CLAIM FOR A FRACTURED ARM UNDER OUR CASUALTY BENEFITSERVICE PROVIDERS SERVICE PROVIDERS


CASUALTY BENEFIT WILL COVER

YOU ARE LIABLE FOR

Treating Doctor R 1 242.30 R 0 R 1 242.30 R 0

Facility Fee R 250.00 R 0 R 250.00 R 0

Total R 1 492.30 R 0 R 1 492.30 R 0

Our ACCESS OPTIMISER BENEFIT provides you with the necessary cover when a medical procedure is required that is not claimable from your medical scheme, because the procedure is listed as a specific exclusion.

We cover your hospital and service providers’ accounts up to a rand amount limit for specific medical procedures.

The claims example below indicates the amount covered for a specific medical procedure which was excluded by the medical scheme.

CLAIM FOR A KNEE ARTHROSCOPY UNDER OUR ACCESS OPTIMISER BENEFITSERVICE PROVIDERS SERVICE PROVIDERS


ACCESS OPT. BENEFIT WILL COVER

YOU ARE LIABLE FOR

Specialist R 14 869.74 R 0 R 14 869.74 R 0

Anaesthetist R 1 686.94 R 0 R 1 686.94 R 0

Hospital R 13 662.35 R 0 R 13 662.35 R 0

Total R 30 219.03 R 0 R 30 219.03 R 0

Our GAP BENEFIT provides shortfall cover, when you become liable for the difference between what your service providers charge and what your medical scheme pays for account shortfalls related to doctors and specialists.

CLAIMS EXAMPLES



ACCESS OPTIMISER

Our ACCESS OPTIMISER option has been skilfully designed to provide you with the necessary cover for a medical procedure that is not claimable from your medical scheme, because the procedure is listed as a specific exclusion.

GAP COVER FOR INDIVIDUALS WITH AN OVERALL POLICY LIMIT (OPL) OF R 100 000 PER POLICY PER YEAR OR WHEN ADDING OUR GAP BENEFIT INCREASES TO R 150 000 PER POLICY PER YEAR

R 65

R 115

R 235

R 285

MONTHLY PREMIUM

64 and younger

65+ *

Family

FamilyAdd our Gap Benefit

Add our Gap Benefit

Single or

Single or







ENTRY AGES



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Our ACCESS OPTIMISER BENEFIT leaves you feeling comforted and confident knowing that when your medical scheme does not cover specific medical procedures that are excluded but necessary for your wellbeing, your gap cover provider will.

WHEN WE COVER YOU

• You are covered when your medical scheme excludes a medical procedure that forms part of a specific list of exclusions, over and above the general exclusions applicable to your medical scheme option, leaving you liable to pay all hospital and related service providers’ accounts in full.


• Our ACCESS OPTIMISER BENEFIT provides cover for your hospital and service providers’ accounts up to the rand amount limit for the below listed medical procedures:

MEDICAL PROCEDURE NOT COVERED BY YOUR MEDICAL SCHEME

ACCESS OPTIMISER BENEFIT WILL COVER

Arthroscopic surgery R 50 000

Back or neck surgery R 50 000

Bunion surgery R 14 000

Cochlear implant, auditory brain implant and internal nerve stimulator surgery including the device and processor

R 80 000

Dental procedures for impacted teeth for child dependants under 18 years of age R 14 000

Dental procedures for reconstructive plastic surgery due to an accident R 80 000

Functional nasal surgery R 23 000

Joint replacement surgery R 50 000

Knee or shoulder surgery R 25 000

Oesophageal reflux and hiatus hernia surgery R 55 000

Varicose veins surgery R 20 000

IMPORTANT TO KNOW

Our ACCESS OPTIMISER BENEFIT grants you the freedom of choice when your doctor informs you that you require a medically necessary procedure but your medical scheme excludes the procedure because it is listed as a specific exclusion. We do not decide which service providers you may use but allow you to inform us of whom you trust.

The rand amount limits our ACCESS OPTIMISER BENEFIT provides for the medical procedure you require, will be used to cover all service providers’ costs. You will be liable for the difference where your chosen service providers charge a rate that exceeds the rand amount limit we provide. You will be required to provide us with a quotation from each service provider, whom we will contact on your behalf and provide a guarantee of payment where applicable. Payment will be made directly to the service providers once your claim has been approved.

ADD OUR GAP BENEFIT Our ACCESS OPTIMISER BENEFIT covers medically necessary procedures that your medical scheme won’t.

When our GAP BENEFIT is added at an additional monthly premium as per the premium breakdown, the shortfall that exists between what your medical scheme pays and the fee charged for private healthcare for medical procedures that do not form part of your medical scheme’s list of specific exclusions, will be covered.

WHY WE COVER YOU


WHEN WE COVER YOU







• Basic radiology


• Pathology

• Physiotherapy



Where a claim under our ACCESS OPTIMISER BENEFIT is received for a condition, procedure, surgery, treatment or an investigation and any related accounts in respect of Arthroscopic surgery, Back or neck surgery, Bunion surgery, Cochlear implant, auditory brain implant and internal nerve stimulator surgery including the device and processor, Dental procedures for impacted teeth for child dependants under 18 years of age, Dental procedures for reconstructive plastic surgery due to an accident, Functional nasal surgery, Joint replacement surgery, Knee or shoulder surgery, Oesophageal reflux and hiatus hernia surgery, Varicose veins surgery within the first 10 months of cover, and is not deemed as pre-existing or accidental, 20% of the total claim amount will be payable.



WHY WE COVER YOU

Our ACCIDENTAL DEATH BENEFIT offers you and your spouse the security of knowing that when you are faced with unexpected change due to the loss of a loved one, we have you covered.


• Our ACCIDENTAL DEATH BENEFIT provides a payment of R 5 000 in the event of the accidental death of the principal insured or spouse.


T’S & C’S APPLY | E&OE18

GAP BENEFIT (Optional to add)ACCESS OPTIMISER BENEFIT

ADDITIONAL BENEFIT

ACCIDENTAL DEATH BENEFIT

INSURED BY CONSTANTIA INSURANCE COMPANY LIMITED (FSP 31111) AND UNDERWRITTEN BY AMBLEDOWN FINANCIAL SERVICES (PTY) LTD (FSP 10287)THESE POLICIES ARE NON-MEDICAL SCHEME PRODUCTS, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP


GAP BENEFITOur GAP BENEFIT provides an additional 200% or 500% cover, when you become liable for the difference between what your service providers charge and what your medical scheme pays from your medical scheme hospital benefit for account shortfalls related to the following:• Doctors and specialists• Dentistry and related procedures• Basic radiology• Specialised radiology limited to MRI, CT and PET scans• Pathology• Physiotherapy• Consumable items such as surgical gloves, bandages and gauze• Medication provided as part of your in- or out-of-hospital event

BENEFIT

Our GAP BENEFIT, providing an additional 500% cover, can be taken voluntarily at an additional premium per month.

OVERALL POLICY LIMIT (OPL)Our gap cover options are subject to OVERALL POLICY LIMITS (OPL’s) per year.

Subject to an OVERALL POLICY LIMIT (OPL) of R 150 000 per person per year.

Subject to an OVERALL POLICY LIMIT (OPL) of R 150 000 per year.




Our ACCESS OPTIMISER option is subject to an OVERALL POLICY LIMIT (OPL) of R 100 000 per policy per year or when adding our GAP BENEFIT increases to R 150 000 per policy per year.

Additional 200% cover. Additional 200% cover. Additional 500% cover. Additional 500% cover. Additional 500% cover.

Dentistry and related procedures limited to R 3 000 per year.

Specialised radiology limited to R 2 000 per year.

Dentistry and related procedures limited to R 3 000 per policy per year.

Specialised radiology limited to R 2 000 per policy per year.









EDGE 200 COMPACT 200 BASE CO-EVOLUTION ELITE ACCESS OPTIMISER

Our EDGE200 option has been innovatively designed to give you the best start when insuring yourself against unforeseen medical shortfalls. We cover you, as the only individual insured on this option, when your medical scheme does not pay your private healthcare fees in full, remove the anxiety of unforeseen expenses for a casualty event and cover your gap cover policy premium when life happens.

Our COMPACT200 option has been conceptualised with medical scheme members in mind because when account shortfalls affect your financial wellbeing, we’ll absorb the impact. Complete peace of mind is offered by our comprehensive benefits that fill the gaps in your medical scheme cover. We cover you when your medical scheme does not pay your private healthcare fees in full, refund upfront co-payment costs and lend a helping hand when you need oncology treatment.

Our BASE option provides real cover with real benefits when your medical scheme does not pay your private healthcare fees in full, when the unforeseen expense of a casualty event causes anxiety and lends emotional and financial support when circumstances outside of your control alter the course of your life.

Our CO-EVOLUTION option has been expertly combined to provide just the right benefits when unforeseen medical expenses occur. From covering the gap that exists when your medical scheme does not pay your private healthcare fees in full, to benefits for co-payments, casualty events, trauma counselling, cancer diagnosis and accidental death, you can rest assured that we have you covered.

Our ELITE option has been thoughtfully created with a clear vision to provide elite benefits that offer best-in-class cover to ensure complete peace of mind knowing we have you covered. This option is perfectly suited for individuals who don’t compromise on cover. We don’t.

Our ACCESS OPTIMISER option has been skilfully designed to provide you with the necessary cover for a medical procedure that is not claimable from your medical scheme, because the procedure is listed as a specific exclusion.

GAP BENEFITCO-PAYMENT BENEFITONCOLOGY BENEFITONCOLOGY OPTIMISER BENEFITCANCER DIAGNOSIS BENEFITSUB-LIMIT BENEFITCASUALTY BENEFITTRAUMA COUNSELLING BENEFITN/AN/AADDITIONAL BENEFIT N/A

N/A


GAP BENEFITN/AN/AN/ACANCER DIAGNOSIS BENEFITN/ACASUALTY BENEFITTRAUMA COUNSELLING BENEFITN/AN/AADDITIONAL BENEFIT N/A

N/A


GAP BENEFITCO-PAYMENT BENEFITN/AN/ACANCER DIAGNOSIS BENEFITN/ACASUALTY BENEFITTRAUMA COUNSELLING BENEFITN/AN/AADDITIONAL BENEFIT N/A

N/A


GAP BENEFITCO-PAYMENT BENEFITONCOLOGY BENEFITONCOLOGY OPTIMISER BENEFITCANCER DIAGNOSIS BENEFITSUB-LIMIT BENEFITCASUALTY BENEFITTRAUMA COUNSELLING BENEFITREHAB OPTIMISER BENEFITPREVENTATIVE CARE BENEFITADDITIONAL BENEFITS GAP POLICY PREMIUM WAIVER BENEFITMEDICAL SCHEME CONTRIBUTION WAIVER BENEFITACCIDENTAL DEATH BENEFIT

EDGE 200 COMPACT 200 BASE CO-EVOLUTION ELITE ACCESS OPTIMISER

BENEFIT OVERVIEW2018 PRODUCT OVERVIEW

GAP COVER PRODUCT RANGE OVERVIEW

GAP BENEFITN/AN/AN/AN/AN/ACASUALTY BENEFITN/AN/AN/AADDITIONAL BENEFIT GAP POLICY PREMIUM WAIVER BENEFITN/A

N/A

T’S & C’S APPLY | E&OE 19INSURED BY CONSTANTIA INSURANCE COMPANY LIMITED (FSP 31111) AND UNDERWRITTEN BY AMBLEDOWN FINANCIAL SERVICES (PTY) LTD (FSP 10287)THESE POLICIES ARE NON-MEDICAL SCHEME PRODUCTS, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP


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ONCOLOGY BENEFITYou are covered when your medical scheme only pays a portion towards your approved oncology treatment such as radiotherapy, chemotherapy, basic and specialised radiology, pathology, specialist consultations, registered oncology facility fees, biological or specialised medication etc.

Our ONCOLOGY BENEFIT covers you when your medical scheme only pays a portion towards your service providers’ accounts.

ONCOLOGY OPTIMISER BENEFITYou are covered when your medical scheme provides you with an oncology benefit but applies a rand amount limit from which you can claim per year. Once this rand amount limit is reached, you will be liable to pay all treatment costs thereafter.

Our ONCOLOGY OPTIMISER BENEFIT covers your oncology treatment costs when your medical scheme no longer does.

Our ONCOLOGY BENEFIT does not have a benefit limit but is subject to the OPL.

Our ONCOLOGY BENEFIT does not have a benefit limit but is subject to the OPL.

CANCER DIAGNOSIS BENEFITOur DIAGNOSIS BENEFIT provides a once-off payment when you are diagnosed with cancer for the first time and the diagnosis aligns to specific qualifying criteria.

Our CANCER DIAGNOSIS BENEFIT provides a once-off payment of R 15 000, not subject to the OPL.


SUB-LIMIT BENEFITOur SUB-LIMIT BENEFIT provides cover when you become liable to settle a portion of your internal prosthesis provider’s account, or the service providers’ accounts relating to your non-PMB day procedure or renal dialysis treatment, as indicated.

CO-PAYMENT BENEFITOur CO-PAYMENT BENEFIT covers in- and out-of-hospital medical procedure related and specialised radiology scan co-payments, deductibles or hospital admission fees, represented as either a rand amount or a percentage.

Our CO-PAYMENT BENEFIT is limited to R 15 000 per policy per year.

Our CO-PAYMENT BENEFIT is limited to R 50 000 per policy per year.

Our CO-PAYMENT BENEFIT does not have a benefit limit but is subject to the OPL.

You will also be covered for1 co-payment up to an amount of R 8 500 per policy per year, for the voluntary use of a non-DSP.

Our ONCOLOGY OPTIMISERBENEFIT is limited to R 50 000 per person per year.

Our ONCOLOGY OPTIMISERBENEFIT does not have a benefit limit but is subject to the OPL.



Our SUB-LIMIT BENEFITprovides cover for your internal prosthesis provider’s account, up to R 15 000 per event with a maximum of R 30 000 per person per year.

Our SUB-LIMIT BENEFITprovides cover for your internal prosthesis provider’s account, or the service providers’ accounts relating to your non-PMB day procedure or renal dialysis treatment, up to R 30 000 per event with a maximum ofR 60 000 per person per year.

You will also be covered for 2 MRI or CT scans up to an amount of R 2 500 per scan per policy per year, when you become liable to settle a portion of, or the full amount of your service provider’s account.

BENEFIT EDGE 200 COMPACT 200 BASE CO-EVOLUTION ELITE ACCESS OPTIMISER

T’S & C’S APPLY | E&OE20 INSURED BY CONSTANTIA INSURANCE COMPANY LIMITED (FSP 31111) AND UNDERWRITTEN BY AMBLEDOWN FINANCIAL SERVICES (PTY) LTD (FSP 10287)THESE POLICIES ARE NON-MEDICAL SCHEME PRODUCTS, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP


CASUALTY BENEFITOur CASUALTY BENEFIT covers the cost of your casualty event for:• Doctors and specialists• Basic and specialised radiology• Pathology• Consumable items such as surgical gloves, bandages and gauze• Medication provided as part of your casualty event at the registered medical facility• Upfront casualty co-payments or facility fees

TRAUMA COUNSELLING BENEFITOur TRAUMA COUNSELLING BENEFIT covers your consultation fees in the event that you witnessed or were directly affected by an act of physical violence or an accident resulting in serious bodily injury or death, when you are diagnosed with a dread disease or are affected by a loved one’s diagnosis of a dread disease or death.

Our TRAUMA COUNSELLINGBENEFIT is limited to R 6 000 per policy per year.


Our CASUALTY BENEFIT is limited to R 6 000 per policy per year.


ADDITIONAL BENEFITSOur GAP POLICY PREMIUM WAIVER BENEFIT covers your Stratum Benefits policy premium in the event of death, permanent disability or forced retrenchment of the Stratum Benefits policy premium payer.

Our REHABILITATION OPTIMISER BENEFIT is limited to R 10 000 per person per year.



Our GAP POLICY PREMIUMWAIVER BENEFIT covers your Stratum Benefits policy premium for 12 months in the event of death, permanent disabilityor forced retrenchment of the Stratum Benefits policy premium payer, not subject to the OPL.

Our GAP POLICY PREMIUMWAIVER BENEFIT covers your Stratum Benefits policy premium for 12 months in the event of death, permanent disabilityor forced retrenchment of the Stratum Benefits policy premium payer, not subject to the OPL.




REHABILITATION OPTIMISER BENEFITOur REHABILITATION OPTIMISER BENEFIT covers your rehabilitation treatment costs when your medical scheme provides you with a rehabilitation benefit for accidental events but applies a rand amount limit or a limit to the number of days you may be admitted from which you can claim per year. Once these limits are reached, you will be liable to pay all treatment costs thereafter.

You are covered for rehabilitation treatment provided by on-site therapists as well as your stay at a registered sub-acute or step-down facility when your medical scheme no longer does.

PREVENTATIVE CARE BENEFITOur PREVENTATIVE CARE BENEFIT covers your consultation fee or the cost of a Pap smear, prostate screening (PSA test) or full blood count (FBC test) to help diagnose certain cancers.

Our PREVENTATIVE CARE BENEFIT is limited to R 500 per policy per year.


Our MEDICAL SCHEME CONTRIBUTION WAIVER BENEFITcovers your medical scheme contribution in the event of death or permanent disability of the medical scheme contribution payer.

Our MEDICAL SCHEME CONTRIBUTION WAIVERBENEFIT covers your medical scheme contribution for6 months to a maximum of R 4 500 per month, in the event of death or permanent disability of the medical scheme contribution payer, not subject to the OPL.

T’S & C’S APPLY | E&OE 21INSURED BY CONSTANTIA INSURANCE COMPANY LIMITED (FSP 31111) AND UNDERWRITTEN BY AMBLEDOWN FINANCIAL SERVICES (PTY) LTD (FSP 10287)THESE POLICIES ARE NON-MEDICAL SCHEME PRODUCTS, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP


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Our ACCIDENTAL DEATH BENEFIT provides a lump sum payment in the event of the accidental death of the principal insured, spouse or dependant, as indicated. Our ACCIDENTAL DEATH

BENEFIT provides a payment of R 5 000 in the event of the accidental death of the principal insured or spouse, not subject to the OPL.

Our ACCIDENTAL DEATHBENEFIT provides a payment of R 15 000 in the event of the accidental death of the principal insured or spouse, and R 5 000 for the accidental death of a dependant, not subject to the OPL.

Our ACCIDENTAL DEATHBENEFIT provides a payment of R 6 000 in the event of the accidental death of the principal insured or spouse, not subject to the OPL.

Our ACCIDENTAL DEATHBENEFIT provides a payment of R 7 000 in the event of the accidental death of the principal insured or spouse, not subject to the OPL.

Our ACCIDENTAL DEATHBENEFIT provides a payment of R 25 000 in the event of the accidental death of the principal insured or spouse, and R 5 000 for the accidental death of a dependant, not subject to the OPL.

ACCESS OPTIMISER BENEFIT

Our ACCESS OPTIMISER BENEFIT provides cover when your medical scheme excludes a medical procedure that forms part of a specific list of exclusions, over and above the general exclusions applicable to your medical scheme option, leaving you liable to pay all hospitalisation and related service providers’ accounts in full.

Our ACCESS OPTIMISERBENEFIT provides cover for your hospital and service providers’ accounts up to a specifiedrand amount limit per medical procedure not covered by your medical scheme.


WE COVER • You, whether you are the main member or dependant on a medical scheme option.

• You, as the only individual insured on this option.

MONTHLY PREMIUMR 180R 210

R 350

64 AND YOUNGER

65+ *

Family

FamilySingle or

Single


R 100

R 180

R 300

18 - 27 *

28 - 64 *

65+ *

Single

Single

Single*Limited to one insured individual per policy

R 180R 205

R 350

64 AND YOUNGER

65+ *

Family

FamilySingle or

Single


R 200R 250

R 400

64 AND YOUNGER

65+ *

Family

FamilySingle or

Single


R 295R 355

R 575

64 AND YOUNGER

65+ *

Family

FamilySingle or

Single


R 65

R 115

R 235

R 285

64 AND YOUNGER

65+ *

Add Gap Benefit

Add Gap Benefit

Family

Family

Single or

Single or


INDIVIDUALS 64 AND YOUNGER• We cover you and your spouse on one policy, even if you belong to different medical schemes or medical scheme options, including all dependants registered on your or your

spouse’s medical scheme option.

INDIVIDUALS 65 AND OLDER• We cover you and your spouse on one policy, even if you belong to different medical schemes or medical scheme options, or you and one other dependant registered on your

medical scheme option.


W ith the essential healthcare needs of the majority of

South Africans in mind, we have passionately created a short-term health insurance solution in partnership with Unity Health that focuses on the healthcare needs of individuals from all walks of life.

To ensure quality and affordable healthcare remain within your reach, Unity Health has contracted with various private healthcare providers at discounted rates to include benefits for doctor consultations, acute and chronic medication, basic blood tests and x-rays, basic and emergency dentistry, basic eye care and maternity care.

In addition, hospitalisation benefits for accidents and emergencies are included to make provision for each individual’s constitutional right to receive treatment in either a private of public facility.

Not only do we take our responsibility in contributing to the socio-economic development of our country seriously, but also each client’s health and wellbeing. We believe a healthy body helps you lead your best life and therefore offer a wellness assessment benefit that provides you with the necessary health checks when you need peace of mind about the status of your health. You also have access to a telephonic assistance programme that offers counselling and advisory services when the storms of life get you down and you need an extra boost to face life head-on.

Stratum Health Insure – committed to the nation and committed to you.

T’S & C’S APPLY | E&OE 23INSURED BY CONSTANTIA INSURANCE COMPANY LIMITED (FSP 31111) AND UNDERWRITTEN BY AMBLEDOWN FINANCIAL SERVICES (PTY) LTD (FSP 10287)


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ESSENTIAL PRIMARY PLUS

Our ESSENTIAL PRIMARY PLUS option has been created to provide a choice between DAY-TO-DAY and EMERGENCY & ACCIDENTAL benefits because we understand that every individual is unique. Whether belonging to a medical scheme or not, access to the very best essential and affordable health insurance is within your reach, providing cover to you, your spouse and any child dependant of whom you are the parent or legal guardian.

Our HEALTH INSURE clients have unlimited access to any Unity Health network doctor nationwide. No upfront payments are required when you visit a network provider because your Stratum Health Insure and Unity Health client card identifies you as a registered client, allowing you to access the benefits that you need.

Rest assured that you have found a healthcare partner that not only covers you, but gets you.

IN PARTNERSHIP WITH

T’S & C’S APPLY | E&OE24 INSURED BY CONSTANTIA INSURANCE COMPANY LIMITED (FSP 31111) AND UNDERWRITTEN BY AMBLEDOWN FINANCIAL SERVICES (PTY) LTD (FSP 10287)


ESSENTIAL PRIMARY PLUS

Our comprehensive and essential DAY-TO-DAY BENEFITS, which can be taken as a stand-alone benefit option, are provided by Unity Health’s network of service providers consisting of approximately 1 800 doctors, 2 274 dentists, 2 582 optometrists as well as various pharmacies, pathologists and radiologists.

DAY-TO-DAY BENEFITS

DAY-TO-DAY BENEFITS UNIQUE FEATURESDOCTOR VISITS You and your loved ones have access to unlimited visits at any Unity Health network doctor.BASIC MEDICAL PROCEDURES Your network doctor can perform minor medical and surgical procedures in the rooms such as removal of a mole or draining of an abscess.

ACUTE MEDICATION

DISPENSING NETWORK DOCTOR

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

Acute medication that is provided by your dispensing network doctor in the rooms is unlimited.

NON-DISPENSING NETWORK DOCTOR

A non-dispensing network doctor will prescribe acute medication according to a formulary that can be collected at any Mediscor pharmacy, which includes pharmacies such as Clicks and Dis-Chem.

Acute medication that is prescribed by your non-dispensing network doctor is limited to R 2 750 per person per year.

CHRONIC MEDICATION

Chronic conditions or diseases, such as diabetes, can be treated by your network doctor.

Chronic medication can be provided or prescribed by your network doctor according to a formulary, for the following chronic conditions or diseases:

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

BASIC BLOOD TESTS & X-RAYSYour network doctor must refer you for basic blood tests, such as a cholesterol or glucose test, or basic x-rays, such as a chest x-ray during one of your visits.

Blood tests and x-rays are subject to an approved list of tariff codes.

BASIC & EMERGENCY DENTISTRY

Basic dental procedures, such as a full mouth assessment, fillings and extractions and emergency dental procedures, such as treatment of an abscess or emergency root canal can be provided by your Unity Health network dentist.

Basic and emergency dental procedures are subject to an approved list of tariff codes, limited to R 1 100 per person per event and R 3 300 per family every 2 years.

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

ACCIDENTAL DENTISTRY When you need urgent dental treatment for an unexpected physical injury that causes loss or damage to your teeth, such as a broken tooth, your network dentist can provide you with treatment to a maximum of R 2 200 per person per event and R 6 600 per family every 2 years.

BASIC EYE CARE

Your nearest PPN network optometrist can provide an eye test and prescribe glasses when you need basic eye care.

You are covered for 1 eye test per person every year, as well as 1 standard frame to the value of R 195 per person and 1 pair of clear monofocal or bifocal lenses per person every 2 years.

Additional optional extras, such as tinting, anti-reflective and scratch resistant coatings are not covered.

MATERNITY CAREYou may consult with any gynaecologist of your choice when you, the soon-to-be-mom, need one-on-one consultations to get advice about your health during your pregnancy.

Our benefit provides 2 maternity check-ups including ultrasound scans during your visits, limited to R 2 600 per policy per year.

WE COVER• You, your spouse and any child dependant of whom you are the parent or legal guardian.

• Child dependants up to the age of 21 at a child dependant premium and full time students over the age of 21 at an adult dependant premium, provided proof of studies is submitted yearly.

• You, whether you belong to a medical scheme or not.

BENEFIT OPTION ENTRY AGEMONTHLY PREMIUM

PRINCIPAL INSURED

SPOUSE ADULT DEPENDANT FULL TIME STUDENTS OVER 21

CHILD DEPENDANT UP TO AGE 21

DAY-TO-DAY BENEFITS ONLY55 and younger R 315 R 210 R 210 R 8556 and older R 465 R 360

EMERGENCY & ACCIDENTAL BENEFITS ONLY

60 and younger R 135 R 75 R 75 R 3061 and older R 170 R 110

DAY-TO-DAY AND EMERGENCY & ACCIDENTAL BENEFITS

55 and younger R 405 R 290 R 290 R 10556 and older R 580 R 465

BENEFIT OPTION ENTRY AGEMONTHLY PREMIUM

PRINCIPAL INSURED

SPOUSE ADULT DEPENDANT FULL TIME STUDENT 21+

CHILD DEPENDANT 20 AND YOUNGER

DAY-TO-DAY BENEFITS ONLY55 and younger R 315 R 210 R 210 R 8556+ R 465 R 360 -- --

EMERGENCY & ACCIDENTAL BENEFITS ONLY

60 and younger R 135 R 75 R 75 R 3061+ R 170 R 110 -- --

DAY-TO-DAY AND EMERGENCY & ACCIDENTAL BENEFITS

55 and younger R 405 R 290 R 290 R 10556+ R 580 R 465 -- --

HEALTH INSURANCE FOR INDIVIDUALS OFFERING A CHOICE BETWEEN DAY-TO-DAY BENEFITS, EMERGENCY & ACCIDENTAL BENEFITS OR A COMBINATION OPTION

T’S & C’S APPLY | E&OE 25INSURED BY CONSTANTIA INSURANCE COMPANY LIMITED (FSP 31111) AND UNDERWRITTEN BY AMBLEDOWN FINANCIAL SERVICES (PTY) LTD (FSP 10287)


EMERGENCY & ACCIDENTAL BENEFITS UNIQUE FEATURESOVERALL POLICY LIMIT (OPL) Each benefit has its own rand amount limit but when combined cannot exceed R 1 000 000 per policy per year.

HOSPITALISATION DUE TO AN EMERGENCY

You are covered at your nearest private hospital when you need immediate treatment in the event of a medical emergency that requires you to be stabilised before being transferred to a public facility, should you need further treatment.

An emergency is an event or unexpected health condition that can result in death or serious bodily impairment if not treated immediately, such as a heart attack or stroke.

Our benefit is limited to R 17 500 per person per event, subject to the OPL.

HOSPITALISATION DUE TO AN ACCIDENT

We cover you when you need immediate treatment due to accidental impact, which results in severe physical injury.

Examples of accidents are motor vehicle accidents where you sustained severe injuries, injuries from a crime or a snake bite.

Our benefit is limited to R 1 000 000 per person per event, subject to the OPL.

CASUALTY FACILITYWhen you need immediate treatment for minor physical injury that is caused by an external force, you are covered at a private hospital’s casualty facility to a benefit limit of R 5 000 per person per event, subject to the OPL.

Visits to a casualty facility can be due to minor injuries caused by vehicle accidents or from working with factory machinery.

24 HOUR MEDICAL EMERGENCY SERVICES

When life happens and every second matters, our national emergency partners will be standing by to provide essential emergency assistance.

You have access to:

• Our national 24-hour emergency contact centre • Emergency transport services by air or road

• Ambulance transfers between hospitals• Telephonic medical advice

• Repatriation of a loved one’s mortal remains within the borders of South Africa

ACCIDENTAL DEATH BENEFITOur benefit offers a lump sum payment when you are faced with unexpected change due to the loss of a loved one.

We provide a payment of R 10 000 in the event of the accidental death of the principal insured or spouse registered on the health insurance policy, not subject to the OPL.

ESSENTIAL WELLNESS BENEFITS UNIQUE FEATURES

WELLNESS ASSESSMENT BENEFIT

Your nearest Dis-Chem pharmacy provides the necessary wellness assessment when you need peace of mind about the status of your health. The wellness assessment is done by registered nurse practitioners at a Dis-Chem clinic in an enclosed private consultation room.

Our WELLNESS ASSESSMENT BENEFIT includes the following health checks:

• Blood pressure• Cholesterol

• Glucose levels• Body Mass Index (BMI)

• Waist circumference• HIV including pre- & post-test counselling

Our benefit is limited to 1 assessment per person per year.

ESSENTIAL ASSISTANCE PROGRAMME (EAP)

When the storms of life get you down and you need advice and guidance, you have access to our ESSENTIAL ASSISTANCE PROGRAMME (EAP) that provides unlimited telephonic advisory and counselling services.

Our EAP benefit is available 24/7 and includes advice and counselling for:

• Trauma counselling• HIV counselling

• Legal advice• Financial advice

When you need an extra boost to face life head-on, personal face-to-face counselling can be arranged for your own pocket.

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Our unique EMERGENCY & ACCIDENTAL BENEFITS, which can be taken as a stand-alone benefit option, are provided by your nearest, registered private hospital and the hospital’s casualty facility. When you are admitted into a private facility for a planned medical procedure, cover is not applicable.

Our ESSENTIAL WELLNESS BENEFITS provide access to a wellness assessment and a telephonic assistance programme consisting of counselling and advisory services that are automatically included when you join our DAY-TO-DAY-, or DAY-TO-DAY AND EMERGENCY & ACCIDENTAL BENEFITS health insurance option, because we believe a healthy body and a focused mind help you lead your best life.

Our stand-alone EMERGENCY & ACCIDENTAL BENEFITS health insurance option includes access to only our ESSENTIAL ASSISTANCE PROGRAMME (EAP) when sound advice is needed most.

EMERGENCY & ACCIDENTAL BENEFITS

ESSENTIAL WELLNESS BENEFITS

T’S & C’S APPLY | E&OE26 INSURED BY CONSTANTIA INSURANCE COMPANY LIMITED (FSP 31111) AND UNDERWRITTEN BY AMBLEDOWN FINANCIAL SERVICES (PTY) LTD (FSP 10287)OUR GAP COVER POLICIES ARE NON-MEDICAL SCHEME PRODUCTS, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP


THE CLEAR PRINT

We believe in consistently communicating in a simple, clear and concise manner and have therefore removed the insurance jargon so that you don’t have to read between the lines.

YOUR GAP COVER POLICY WAITING PERIODSFrom the first day your cover starts, waiting periods will apply before you are able to claim from specific policy benefits.

3 MONTH GENERAL WAITING PERIODWithin the first 3 months of cover a general waiting period will apply, where no claims can be submitted unless you are claiming for an injury resulting from an accident caused by physical impact.

12 MONTH PRE-EXISTING CONDITION WAITING PERIODWithin the first 12 months of cover a waiting period for pre-existing medical conditions will apply, where no claims can be submitted for a procedure, surgery, treatment or an investigation relating to any illness or condition for which you received advice or treatment 12 months prior to your cover start date.

YOUR HEALTH INSURE POLICY WAITING PERIODS From the first day your cover starts, waiting periods will apply to the DAY-TO-DAY BENEFITS on your ESSENTIAL PRIMARY PLUS option.

2 MONTH GENERAL WAITING PERIOD Within the first 2 months of cover a general waiting period will apply to all benefits.

9 MONTH MATERNITY CARE WAITING PERIOD

Within the first 9 months of cover a waiting period will apply to the MATERNITY CARE benefits.

12 MONTH BASIC EYE CARE & CHRONIC MEDICATION WAITING PERIOD Within the first 12 months of cover a waiting period will apply to the BASIC EYE CARE and CHRONIC MEDICATION benefits.

EXCEPTIONS TO THE RULE• A 2 Month General Waiting Period applies to the ESSENTIAL WELLNESS

BENEFITS on your ESSENTIAL PRIMARY PLUS option.

• Waiting periods do not apply to the EMERGENCY & ACCIDENTAL BENEFITS on your ESSENTIAL PRIMARY PLUS option.

T’S & C’S APPLY | E&OE 27INSURED BY CONSTANTIA INSURANCE COMPANY LIMITED (FSP 31111) AND UNDERWRITTEN BY AMBLEDOWN FINANCIAL SERVICES (PTY) LTD (FSP 10287)OUR GAP COVER POLICIES ARE NON-MEDICAL SCHEME PRODUCTS, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP


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GAP COVER BENEFIT EXCLUSIONSWHAT OUR BENEFITS DO NOT COVERGAP BENEFIT DOES NOT COVER

1) Service providers’ accounts;

a) where the shortfall is more than what our gap benefit provides. b) that are covered in full or covered as a concession from your medical scheme

hospital benefit, where no shortfalls exist. c) where your medical scheme did not pay a portion towards the account, or

towards an individual line item on the account from your medical scheme hospital benefit.

d) where your medical scheme paid a portion of, or the full amount of the account from your medical scheme savings account or day-to-day benefit, also known as a block or insured benefit.

e) where your medical scheme benefit limit is exceeded.f) where the treatment dates differ from the date of your in- or out-of-hospital

medical event.

2) Consultations in the rooms nor consultations prior to, or following an in- or out-of-hospital medical event.

3) A private upfront fee charged by your doctor or specialist which you are responsible to pay and cannot claim from your medical scheme.

4) Paid by you whilst you are in your medical scheme self-payment gap.

5) Hospital accounts including, but not limited to theatre and ward fees.

6) Specialised radiology except for MRI, CT and PET scans.

7) Consumable items and medication which your medical scheme did not pay during your in- or out-of-hospital medical event, prescription medication or medication provided to take home.

8) Allied service providers’ accounts for diagnostic, technical, therapeutic, direct patient care and support services, such as occupational and speech therapy unless our benefit specifically makes provision for cover.

CO-PAYMENT BENEFIT DOES NOT COVER

1) Co-payments or deductibles applied;

a) where you failed to obtain pre-authorisation or an appropriate service provider referral.

b) where you had not followed your medical scheme rules.c) for the voluntary use of a hospital, day clinic or service provider that does not

form part of your medical scheme’s network, unless our benefit specifically makes provision for cover.

2) Split billing invoicing, where a private upfront fee is charged by your service provider which you are responsible to pay and cannot claim from your medical scheme.

3) Co-payments applied for chronic, acute, formulary or non-formulary medication.

ONCOLOGY BENEFITS DO NOT COVER

1) Cancer treatment costs and biological medication not approved by your medical scheme as part of your initial or ongoing oncology treatment plan.

2) Service providers’ accounts where your medical scheme paid a portion of, or the full amount of the account from your medical scheme savings account or day-to-day benefit, also known as a block or insured benefit.


a) where you had not followed your medical scheme rules.b) for the voluntary use of a service provider that does not form part of your

medical scheme’s network.

4) Our CANCER DIAGNOSIS BENEFIT does not cover a first-time diagnosis;

a) when the cancerous cells have not invaded surrounding or underlying tissue.b) for cancers of the skin except cancerous moles that have invaded underlying

tissue.c) for Stage 1 prostate or breast cancer described as T1a, N0, M0 or G1. (T)

refers to the size of the tumour, (N) to the number of lymph nodes affected, (M) to metastasis and (G) to the grade or aggressiveness of cancer.

d) if your diagnosis is made before the first day your cover starts or whilst your 3 Month General Waiting Period applies.

e) of a second or subsequent diagnosis.f) after the benefit ceased at age 65.

SUB-LIMIT BENEFIT DOES NOT COVER


a) where your medical scheme applied a sub-limit or annual limit to in- or out-of-hospital medical procedures, treatment or investigations except for internal prostheses, non-PMB day procedures, renal dialysis and MRI & CT scans, where applicable.

b) where your medical scheme’s sub-limit or annual limit is exhausted at the time of the event and your medical scheme did not pay a portion towards your service provider’s account, unless our benefit specifically makes provision for cover.

2) Renal dialysis treatment costs not approved by your medical scheme as part of your initial or ongoing dialysis treatment plan, where applicable.

3) Renal dialysis treatment where you had not followed your medical scheme rules and / or for the voluntary use of a service provider that does not form part of your medical scheme’s network, where applicable.

CASUALTY BENEFIT DOES NOT COVER

1) A casualty event that was not due to an accident and / or did not require immediate treatment for physical injury, which resulted from an external force outside of the body due to impact with someone or something.

2) Service providers’ accounts where your medical scheme provided a casualty benefit and paid the accounts in full from your medical scheme hospital benefit.

3) Service providers’ accounts where the treatment dates differ from the date of the casualty event, except for return visits to the registered medical facility where follow-up treatment is required as a result of the initial casualty event.

4) Medication prescribed or provided to take home.

TRAUMA COUNSELLING BENEFIT DOES NOT COVER

1) Registered counsellor’s, clinical psychologist’s or psychiatrist’s accounts if you;

a) did not witness, or were not directly affected by an act of physical violence or an accident resulting in serious bodily injury or death.

b) were not diagnosed with a dread disease, or were not affected by a loved one’s diagnosis of a dread disease or death.

2) Service providers’ accounts where your medical scheme provided a trauma counselling benefit and paid the accounts in full from your medical scheme hospital benefit.

3) The fee charged by your counsellor, clinical psychologist or psychiatrist if they are not registered with a recognised South African regulatory body.

REHABILITATION OPTIMISER BENEFIT DOES NOT COVER

1) Rehabilitation admission or treatment costs not approved by your medical scheme as part of your initial or ongoing rehabilitation treatment plan.


a) where your admission or treatment is not due to a physical injury resulting from an accident.

b) where therapy or treatment is provided off-site or after discharge.c) for counsellors, clinical psychologists or psychiatrists.

3) Rehabilitation admission or treatment costs where you had not followed your medical scheme rules and / or for the voluntary use of a service provider that does not form part of your medical scheme’s network.

4) Rehabilitation facilities providing services other than physical rehabilitation.

5) The fee charged by your service providers if they are not registered with a recognised South African regulatory body.

PREVENTATIVE CARE BENEFIT DOES NOT COVER

1) Service providers’ accounts where your medical scheme provided a preventative screening benefit and paid the accounts in full from your medical scheme hospital benefit.

2) Preventative tests except for a pap smear, prostate screening (PSA test) or full blood count (FBC) to help diagnose certain cancers.

ADDITIONAL BENEFITS

GAP POLICY PREMIUM WAIVER, MEDICAL SCHEME CONTRIBUTION WAIVER & ACCIDENTAL DEATH BENEFITS DO NOT COVER

1) Events where disability is temporary or where retrenchment is voluntary.

2) Death, permanent disability or forced retrenchment of an insured person if that person is not noted as the gap policy premium payer or the medical scheme contribution payer, where applicable.

3) Forced retrenchment, permanent disability and death where the premium or contribution payer’s details changed to another payer’s details 3 months prior to the event, except for accidental permanent disability or death.

4) Death due to natural causes applicable to our ACCIDENTAL DEATH BENEFIT only.

ACCESS OPTIMISER BENEFIT DOES NOT COVER

1) Medical procedures listed as specific exclusions by your medical scheme that do not form part of our list of medical procedures covered.


a) where your medical scheme provides a benefit and paid a portion towards the account.

b) where your medical scheme provides a sub-limit or annual limit from which you can claim for in-hospital medical procedures, but is exhausted at the time of the event.

c) where your chosen service providers charge a rate that exceeds the rand amount limit we provide.

d) that are covered as a concession from your medical scheme hospital benefit, although the medical procedure forms part of the medical scheme’s exclusions.

T’S & C’S APPLY | E&OE28


INSURED BY CONSTANTIA INSURANCE COMPANY LIMITED (FSP 31111) AND UNDERWRITTEN BY AMBLEDOWN FINANCIAL SERVICES (PTY) LTD (FSP 10287)OUR GAP COVER POLICIES ARE NON-MEDICAL SCHEME PRODUCTS, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP

GENERAL EXCLUSIONS APPLICABLE TO YOUR GAP COVER POLICYWe do not cover service providers’ accounts for related medical procedures and / or treatment, hospitalisation, illness, disease, loss, damage, death, bodily injury or liability that is caused by or results from:

1) An event where the claimant is not an insured person at the time of the event, unless a benefit specifically makes provision for cover.

2) Medical scheme exclusions where no underlying cover exists, unless a benefit specifically makes provision for cover.

3) An event where a benefit limit or an Overall Policy Limit (OPL) has been reached.

4) An event where the policy does not provide the relevant benefit to claim from.

5) An event where pre-authorisation was not obtained from the medical scheme or where medical scheme rules were not followed.

6) An event where the use of a hospital, day-clinic or service provider was voluntary and the service provider does not form part of the medical scheme’s network, unless a benefit specifically makes provision for cover.

7) An event that occurs during a policy waiting period, unless otherwise specified.

8) Maxillo-facial surgery and related medical conditions and / or medical procedures unless due to accidental impact resulting in severe physical injury.

9) Dental implants, orthodontic, prosthodontic or cosmetic dentistry.

10) External prostheses or appliances such as artificial limbs, wheelchairs and crutches.

11) Robotic surgery, specialised mechanical or computerised appliances and equipment.

12) Artificial insemination, infertility treatment or contraceptives except for tubal ligation and vasectomies.

13) Obesity.

14) Non-medically necessary reconstructive cosmetic surgery.

15) Breast reconstruction performed as a second or subsequent reconstruction.

16) Home nursing or admission to a step-down facility such as a frail care centre, unless a benefit specifically makes provision for cover.

17) Depression, insanity, emotional or mental illness or any stress-related conditions.

18) Costs associated with supporting medical reports that assist in the finalisation of a claim.

19) Routine physical, diagnostic procedures or examination where there are no objective indications of impairment in normal health.

20) Expenses incurred for transport charges or for services rendered whilst being transported in an emergency vehicle, vessel or aircraft.

21) Riots, wars, political acts, public disorder, terrorism, civil commotions, labour disturbances, strikes, lock-out, or any attempted such acts.

22) 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 injury.

23) Attempted suicide, intentional self-injury and deliberate exposure to exceptional danger except in an attempt to save a human life.

24) An event where the use of drugs or alcohol is involved.

25) Active military, police and police reservist activities whilst on active duty.

26) 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 fission.

27) Events that occur for which the actual damage is provided for by legislation, including contractual liability and consequential loss.

28) Discounts negotiated by an insured person directly with a service provider where reimbursement of a claim will enrich the insured person.

29) Non-disclosure of material information that is likely to affect the assessment or acceptance of risk.

GENERAL EXCLUSIONS APPLICABLE TO YOUR HEALTH INSURE POLICYWe do not cover service providers’ accounts for related medical procedures and / or treatment, hospitalisation, illness, disease, loss, damage, death, bodily injury or liability that is caused by or results from:

1) An event where the claimant is not an insured person at the time of the event.

2) An event where a benefit limit or an Overall Policy Limit (OPL) has been reached.

3) An event where the health insurance policy does not provide the relevant benefit to claim from.

4) An event where pre-authorisation or an appropriate service provider referral was not obtained and / or where the Unity Health guidelines or protocols were not adhered to.

5) An event where a service provider was utilised that does not form part of the Unity Health network, unless otherwise specified.

6) An event where healthcare services, such as consultations, basic medical procedures, acute and chronic medication and basic dentistry do not form part of Unity Health’s list of approved services, tariff codes or benefits.

7) An event that occurs during a policy waiting period, unless otherwise specified.

8) A hospital event that was not due to an accident or an emergency.

9) A hospital event for a planned medical procedure.

10) Costs incurred for the voluntary stay at a private facility following stabilisation due to an emergency.

11) Reconstructive cosmetic surgery and / or maxillo-facial surgery, including related medical conditions and procedures, if not performed during an authorised hospital event resulting from an accident.

12) Contact lenses.

13) External prostheses or appliances, such as artificial limbs.

14) Artificial insemination, infertility treatment or contraceptives.

15) Robotic surgery, specialised mechanical or computerised appliances, equipment and all related service providers’ accounts.

16) Routine physical, diagnostic procedures or examination where there are no objective indications of impairment in normal health.

17) Riots, wars, political acts, public disorder, terrorism, civil commotions, labour disturbances, strikes, lock-out, or any attempted such acts.

18) 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 injury.

19) Attempted suicide, intentional self-injury and deliberate exposure to exceptional danger except when attempting to save a human life.

20) An event where the use of drugs or alcohol is involved.

21) Participation in:

a) Active military, police or police reservist duty.b) Aviation other than as a passenger.c) Hazardous, competitive or professional sports or activities.d) Any form of race or speed test, other than on foot or involving any

non-mechanically propelled vehicle vessel craft or aircraft.

22) 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 fission.

23) Events that occur for which the actual damage is provided for by legislation, including contractual liability and consequential loss.

24) Non-disclosure of material information that is likely to affect the assessment or acceptance of risk.


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