Accommodation

General ward, high-care ward and intensive care unit

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

do_not_disturb_on Subject to the overall annual limit of R2 854 000, this includes in-hospital consultations.

Theatre fees

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

do_not_disturb_on Subject to the overall annual limit of R2 854 000

Medicines, materials and hospital equipment

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

do_not_disturb_on Subject to the overall annual limit of R2 854 000

Specialist consultations and procedures

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

do_not_disturb_on Subject to the overall annual limit of R2 854 000

General practitioner consultations and procedures

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

do_not_disturb_on Subject to the overall annual limit of R2 854 000

Nursing services and all other non-psychiatric, in-hospital services

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

do_not_disturb_on Subject to the overall annual limit of R2 854 000

Confinement and midwives

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

do_not_disturb_on Subject to the overall annual limit of R2 854 000

Combined limit for accommodation, medicines, materials/hospital equipment and consultations

Subject to the overall annual limit.

Limited to 21 days' hospital-based treatment or up to 15 days' outpatient consultations per beneficiary per annum.

Combined limit for accommodation, medicines, materials/hospital equipment and consultations

Subject to the overall annual limit

Limited to 21 days' hospital-based treatment and 3 days' detoxification per beneficiary per annum

Accommodation

warning Subject to pre-authorisation

do_not_disturb_on Subject to overall annual limit of R2 854 000

Step-down nursing facilities

warning Subject to pre-authorisation by the Society's designated agent

do_not_disturb_on Subject to overall annual limit of R2 854 000

Private nursing (instead of hospitalisation)

warning Subject to pre-authorisation by the Society's designated agent

do_not_disturb_on Limited to R37 000 per family per annum

do_not_disturb_on Subject to overall annual limit of R2 854 000

Hospice

warning Subject to pre-authorisation by the Society's designated agent

do_not_disturb_on Subject to overall annual limit of R2 854 000

Post hospitalisation benefit (instead of hospitalisation)

warning Post-hospitalisation and cardiac rehabilitation benefit must be in accordance with an authorised treatment plan

warning Subject to pre-authorisation by the Society's designated agent

do_not_disturb_on Subject to overall annual limit of R2 854 000

do_not_disturb_on 90 days per diagnosis

Hospital prevention

warning Subject to pre-authorisation by the Society's designated agent

warning The Society's designated agent will liaise with the case manager of the hospital and the treating doctor to assess the appropriateness of transferring certain beneficiaries to step-down facilities

The Society's designated agent will arrange for and manage the appropriate alternatives to hospitalisation upon discharge from hospital, such as to join the cardiac rehabilitation programme at an accredited provider, to visit rehabilitation or sub-acute facilities or receive home nursing in accordance with a clinical motivation from doctors and case managers.

do_not_disturb_on Subject to overall annual limit of R2 854 000. Once the sub-limits are reached, only the diagnosis, treatment and care costs for PMB conditions will be paid in full.

Following a hospital event

warning Subject to pre-authorisation

Includes extended physiotherapy and occupational and speech therapy and biokinetics of a rehabilitative nature that is preceded by hospitalisation.

do_not_disturb_on Subject to overall annual limit of R2 854 000

Maintenance therapy

warning Subject to pre-authorisation

Includes extended physiotherapy and occupational and speech therapy and biokinetics of a rehabilitative nature that is preceded by hospitalisation.

do_not_disturb_on Limited to R15 060 per family per annum

do_not_disturb_on Subject to overall annual limit of R2 854 000

Such treatment must be connected to an approved rehabilitative treatment plan and must commence within two weeks of discharge from hospital.

Cardiac rehabilitation benefit

warning Subject to pre-authorisation

The cardiac rehabilitation benefit provides for an initial three-month, intensive rehabilitation benefit followed by a three-month continuing care benefit.

do_not_disturb_on Limited to six months per cardiac event

do_not_disturb_on Subject to overall annual limit of R2 854 000

Basic: All X-rays

warning Subject to pre-authorisation

In the event of an emergency, the Society's designated agent must be notified on the first working day following the procedure.

In respect of PMB conditions, radiology must be detailed in the care plan; treatment to be paid at 100% of cost

do_not_disturb_on R1 610 per beneficiary per annum

do_not_disturb_on Where the treatment is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the service being rendered.

Ultrasounds

warning Subject to pre-authorisation

In the event of an emergency, the Society's designated agent must be notified on the first working day following the procedure.

In respect of PMB conditions, radiology must be detailed in the care plan; treatment to be paid at 100% of cost

do_not_disturb_on Subject to overall annual limit of R2 854 000

do_not_disturb_on Where the treatment is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the service being rendered.

Advanced: Includes MRI and CT Scans/acopes (diagnostics)/angiography/nuclear medicine studies

warning Subject to pre-authorisation

The Society's designated agent must authorise MRI and CT scans, scopes and angiographies, except in emergencies

do_not_disturb_on Subject to overall annual limit of R2 854 000

do_not_disturb_on Where the treatment is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the service being rendered.

PET scans

warning Excludes PET scans, unless authorised as part of a member's oncology treatment or where it is deemed to be clinically appropriate and medically necessary by the Society's designated agent

do_not_disturb_on Subject to overall annual limit of R2 854 000

Blood tests

In respect of PMB conditions, pathology must be detailed in the care plan; treatment to be paid at 100% of cost

do_not_disturb_on Subject to overall annual limit of R2 854 000

Organ transplants

warning Subject to pre-authorisation

The Society will pay for the cost of harvesting the organ from the donor and to transplant it to the recipient if both the donor and the recipient are members of the Society.

Where the donor is a member of the Society and the recipient is not, the costs of harvesting the organ from the donor will not be covered by the Society.

If the recipient is a member of the Society, the harvesting costs will be covered.

Benefit is not adjusted in proportion to the number of months of membership if member joins during benefit year.

do_not_disturb_on R248 250 per family per annum

warning Subject to pre-authorisation

warning Subject to pre-authorisation

Ambulance services

warning Subject to authorisation from the Society's designated service provider (Netcare 911)

warning Failure to obtain authorisation is subject to a 30% co-payment

Such transport is to be certified by a medical practitioner as being essential.

Hip replacements

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

do_not_disturb_on Limits

Bilateral total hip: R88 980 PBPA
Total hip: R51 300 PBPA
Partial hip: R28 550 PBPA
Revision hip: R97 690 PBPA
PBPA: per beneficiary per annum

Knee replacements

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

do_not_disturb_on Limits

Without patella: R56 710 PBPA
With patella: R64 240 PBPA
Bilateral knee: R113 920 PBPA
Revision knee: R98 930 PBPA
PBPA: per beneficiary per annum

Shoulder replacements

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

do_not_disturb_on Limits

Total shoulder: R67 960 PBPA
Bilateral shoulder: R86 600 PBPA
PBPA: per beneficiary per annum

Spinal fusion

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

do_not_disturb_on Limits

Level 1 (without cage): R30 900 PBPA
Level 1 (with cage): R58 890 PBPA
Level 2 (without cage): R41 290 PBPA
Level 2 (with one cage): R65 850 PBPA
Level 2 (with two cages): R96 450 PBPA
PBPA: per beneficiary per annum

Artificial limbs

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

do_not_disturb_on Limits

Below the knee: R29 590 PBPA
Above the knee: R49 690 PBPA
PBPA: per beneficiary per annum

Artificial eyes

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

do_not_disturb_on Limits

R29 590 PBPA
PBPA: per beneficiary per annum

Finger-joint prosthesis

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

do_not_disturb_on Limits

R7 330 PBPA
PBPA: per beneficiary per annum

Pacemakers

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

do_not_disturb_on Limits

With leads: R61 740 PBPA
Biventricular: R101 230 PBPA
PBPA: per beneficiary per annum

Intracardiac devices

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

do_not_disturb_on Limits

do_not_disturb_on R338 770 PBPA
PBPA: per beneficiary per annum

Cardiac valves

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

do_not_disturb_on Limits

R46 320 PBPA
PBPA: per beneficiary per annum

Cardiac stents with delivery system

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

do_not_disturb_on Limits

R33 450 PBPA (maximum of 3 per annum)
PBPA: per beneficiary per annum

Drug-eluting stents

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

do_not_disturb_on Limits

R41 970 PBPA
PBPA: per beneficiary per annum

Aortic aneurism repair grafts

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

do_not_disturb_on Limits

R197 990 PBPA
PBPA: per beneficiary per annum

Cochlear implant

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

do_not_disturb_on Limits

R309 730 PBPA
PBPA: per beneficiary per annum

Other

warning Subject to pre-authorisation by the Society's designated agent or hospital DSP

Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

do_not_disturb_on Limits

R30 650 PBPA
PBPA: per beneficiary per annum