de beers benefit society guide/2014... · de beers benefit society member guide | 3 contents...

De BeersBenefit SocietyMeMBer GuiDeEffective 1 January 2014

2014

Contact details

DE BEERS BENEFIT SOCIETYDis-Chem Pharmacies and Dis-Chem Direct

ER24

(Emergency Transport DSP)

TeLePHONe GeNerAL QuerieS 053 807 3111

HOSPiTAL Pre-AuTHOriSATiON ONLY (rSA) 0800 111 669 or e-mail [email protected]

HOSPiTAL Pre-AuTHOriZATiON NON-rSA MeMBerS +27 53 807 3444 or e-mail [email protected]

Call centre 086 122 6668 FrOM WiTHiN rSA

084 124FOr BOTSWANA Or NAMiBiAN reSiDeNTS +27 10 205 3000

WALK-iN CuSTOMer SerViCeS:

(Physical Address)

De Beers Benefit Society Kimberley House 84 Du Toitspan road, Kimberley

All retail Dis-Chem Pharmacies

Manor 1 Cambridge Manor Office Park Corner Witkoppen & Stone Haven rd Paulshof, Sandton

POSTAL ADDreSS PO Box 1922

Kimberley 8300

Dis-Chem Direct:

PO Box 597, Menlyn, 0063

PO Box 242

Paulshof 2056

WeBSiTe www.dbbs.co.za www.dischem.co.za www.er24.co.za

FAX 053 807 3499 086 529 0228 0866 828 442

e-MAiL [email protected] [email protected] [email protected]

Complaints, Queries & Compliments: [email protected]

The information in this member guide is subject to the registered rules of the De Beers Benefit Society (a registered medical scheme; registration no. 1068). The rules of the Society will apply in all cases should there be any dispute, doubt or misunderstanding arising from the information in this guide. The full set of the Society’s rules can be viewed at the registered office of the Society: 84 Du Toitspan road, Kimberley 8301, a copy can be obtained from your Hr department, from the Society’s website at www.dbbs.co.za or members may request that a printed copy be posted to them. Should you have any queries, please contact the Society on 053 807 3111, or visit the Society’s website at www.dbbs.co.za. You can also visit this website for easy access to all your personal medical information online, provided you have registered to use this facility.

This guide is copyright protected and may not be reproduced in part or whole without the permission of the Trustees.

De Beers Benefit Society Member Guide | 3

Contents

introduction 6

What is the role of the De Beers Benefit Society? 6How can this member guide help me? 6What are my responsibilities as a member? 6What abbreviations are used in this guide? 7

Contributions 8

What are the monthly contributions for 2014? 9

BeNeFiTS: Prescribed Minimum Benefits 10

What are PMBs? 10Why do we have PMBs? 10Who are the Society’s Designated Service Providers for PMBs, and why should i use them? 11How do i register for PMBs? 12What if circumstances force me to use a non-DSP? 12Why does the Society need iCD-10 codes on the invoice from the service provider? 13How do i query an account that i believe should be a PMB? 13Where can i get more information about PMBs? 13

BeNeFiTS: Hospitalisation benefits 14

What are Network Hospitals, and why should i use them? 15How are benefits calculated? 15How will my service providers be paid? 15What is the Scheme rate? 15What is pre-authorisation, and when do i need it? 16How do i obtain pre-authorisation? 16What hospitalisation benefits am i covered for? 16How do benefits for day procedures work? 17How can i minimise costs not covered by the Society if i need to have an operation? 18What if the procedure can be done in the doctor’s rooms? 18What must i do in an emergency? 19

BeNeFiTS: emergency benefits 19

Will emergency admissions to hospital be covered? 20What if the emergency occurs outside South Africa? 20How are medicine benefits provided by the Society? 21What tools are used by the Society to manage medicine benefits? 21

BeNeFiTS: Medicine benefits 21

How can i obtain acute medicine? 23How does the Over-the-Counter (OTC) medicine benefit work? 24What chronic conditions are covered by the Society? 24How do i obtain my chronic medicine? 26How am i required to obtain oncology medicine? 26What if i need an additional supply of chronic medicine due to travelling? 26What else do i need to know about chronic medicines? 27

Contents

4 | De Beers Benefit Society Member Guide

BeNeFiTS: Day-to-day benefits 28

What day-to-day benefits are covered by the Society? 28

BeNeFiTS: Benefit details for 2014 30

important notes 30Prescribed Minimum Benefits 31Consultations (Out-Of-Hospital) 31Diagnostic Testing 32Oncology 33Medicine 33Dental 34Optometry 35Medical equipment 36Care Not in-Hospital 37in-Hospital 38emergency Transport 41Other 41What benefits are excluded by the Society? 42To what extent are benefits limited by the Society? 44Where will i be covered? 45

More about the Society 45

Who manages the Society? 46Who qualifies to be a member? employees 47

All about membership 47

What waiting periods apply to new members? 49

What if a beneficiary has not been a member of a medical aid before? 50Can i or any of my dependants belong to more than one medical scheme at the same time? 50How much time do i have to claim a benefit? 51How can i ensure that my GP and other health-care service providers are paid timeously? 51Can i settle my co-payments by paying service providers directly? 51

Claiming and co-payments 51

How can i avoid co-payments for after-hours/unscheduled doctors’ consultations? 52How are benefits calculated? 53How will my service providers be paid? 53

Frequently asked questions 53

What happens to “unused” benefit limits from the risk pool? 54What do i do if i suspect that someone is defrauding the Society? 54What if i have a complaint against the Society? 54Laying a complaint with the Council for Medical Schemes (CMS) about the Society 56Council for Medical Schemes time limits for dealing with complaints 56The registrar’s ruling and appeal to Council 57The Section 50 Appeals process 57What if i have a complaint related to other aspects of the health industry? 57

List of Network Hospitals 58

introduction


01What is the role of the De Beers Benefit Society?The Society provides medical cover to you and your dependants for a wide range of medical services, prescribed medicine and medical events, such as hospitalisation and surgery.

How can this member guide help me?All your benefits and related conditions and limits are explained in sum-marised form in this guide. This guide is designed to answer most of the general questions you may have. read it carefully and keep it for future reference.

What are my responsibilities as a member?While the Society is accountable for member communication, you have a duty (and are accountable) to ensure that you remain updated regarding the Society’s benefits and developments affecting it, and to act respon-sibly in relation to the Society. That is because members’ behaviour (claiming patterns) has a direct impact on the total costs and therefore an indirect impact on your contributions and the future sustainability and viability of the Society. Specifically, as a member you should -

• use your benefits responsibly.

• Comply with and adhere to the rules of the Society.

• understand how the Society and your benefits work - read all com-

munication sent to you, attend Society information sessions as

appropriate, refer queries to the Society for clarification and provide

the Society with feedback if your information needs are not met.

• What is the role of the De Beers Benefit Society?

• How can this member guide help me?

• What are my responsibilities as a member?

• What abbreviations are used in this guide?

introduction>>

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introduction


• Keep the Society up to date on any changes to your membership

details.

• Check all accounts from service providers as well as your member

statements from the Society to make sure that all your details are

correct and that your claims have been processed correctly.

• Obtain pre-authorisation from the Society before you are admitted

to hospital.

• File all your documentation regarding the Society so that you can

refer to it if necessary.

• Keep your membership card in a safe place so that no one else can

use it fraudulently.

• if you suspect fraudulent activity against the Society, please report it.

• ensure that you notify the Society of your valid postal address

and email address in order to ensure that you receive

your communication.

What abbreviations are used in this guide?The following abbreviations are used in this guide:

CDL Chronic Disease List MCC Medicines Control Council

CMS Council for Medical Schemes Mri Magnetic resonance imaging

CT Computed Tomography OTC Over-the-counter

CPAP Continuous Positive Airway Pressure Device PAT Patient Advised Therapy

DSP Designated Service Provider PeT Positron emission Tomography

GP General Practitioner PMBs Prescribed Minimum Benefits

GrP Generic reference Pricing (for medicines) SeP Single exit Price (for medicines)

iCD-10 international Classification of Disease SrPL Society reference Price List – the rate at which the Society will pay for relevant health services

iCON independent Clinical Oncology Network TTO To-take-out (medicine to take-home from hospital)

iCu intensive Care unit TrP Therapeutic reference Pricing (Formulary)

Introd

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02• What are the monthly

contributions for 2014?

Contributions>>

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Contributions


What are the monthly contributions for 2014?The table below shows the total monthly contributions payable effective from 1 January 2014.

Principal Member / Adult Child Dependant

r 2 305 r 621

Please note that employer subsidies that may apply to the above contributions may vary, as this is determined by your conditions of employment and administered accordingly. Queries in this regard should be directed to your employer. it remains your responsibility, however, to ensure that your monthly contributions are paid in full to the Society.

Co

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BeNeFiTS: Prescribed Minimum Benefits


• What are PMBs?

• Why do we have PMBs?

• Who are the Society’s Designated Service Providers (DSPs) for PMBs, and why should i use them?

• How do i register for PMBs?

• What if circumstances force me to use a non-DSP?

• Why does the Society need iCD-10 codes on my invoice from the service provider?

• How do i query an account that i believe should be a PMB?

• Where can i get more information about PMBs?

03BeNeFiTS: Prescribed Minimum Benefits>>

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What are PMBs?PMBs are minimum benefits which by law must be provided by all medical schemes and includes the provision of diagnosis, treatment and care costs for:

• any emergency medical condition as defined* (see next page)

• a set of 270 medical conditions (called the Diagnosis and Treat-

ment Pairs or DTPs** (see next page), listed in the regulations to

the Act); and

• the Chronic Disease List (26 chronic conditions including HiV

and AiDS)

Why do we have PMBs?PMBs were introduced into the Medical Schemes Act to ensure that members of medical schemes would not run out of benefits for the treatment of certain prescribed conditions. Medical schemes must pay in full, without co-payment or the use of deductibles (co-payments), for the diagnosis, treatment and care costs of the PMB conditions under certain conditions (see page 11). These PMBs cover a wide range of 270 diagnosis and treatment pairs that medical schemes must cover (according to set protocols), including but not limited to medical emergencies.

*Emergency medical condition as defined - This is a medical condition which is of sudden and unexpected onset of a health condition that requires immediate medical and/or surgical treatment, where failure to provide this treatment would result in impairment of bodily functions, serious and lasting dysfunc-tion of a bodily organ or part, or would place the person’s life in serious jeopardy. In the case of such an emergency medical condition, the Society must be informed on the first business day following the date of such admission or treatment.

**DTPs - Certain conditions cannot be classified as a PMB condition on their own. To be classified as a PMB condition, the condition must be treated in a specific way in accordance with set protocols. This is known as Diagnosis and Treatment Pairs (DTPs). Only when all the DTP criteria, as per the reg-ulations, are met will claims for the treatment of the relevant condition be classified as a PMB.



What are PMBs?PMBs are minimum benefits which by law must be provided by all medical schemes and includes the provision of diagnosis, treatment and care costs for:

• any emergency medical condition as defined* (see next page)

• a set of 270 medical conditions (called the Diagnosis and Treat-

ment Pairs or DTPs** (see next page), listed in the regulations to

the Act); and

• the Chronic Disease List (26 chronic conditions including HiV

and AiDS)

Why do we have PMBs?PMBs were introduced into the Medical Schemes Act to ensure that members of medical schemes would not run out of benefits for the treatment of certain prescribed conditions. Medical schemes must pay in full, without co-payment or the use of deductibles (co-payments), for the diagnosis, treatment and care costs of the PMB conditions under certain conditions (see page 11). These PMBs cover a wide range of 270 diagnosis and treatment pairs that medical schemes must cover (according to set protocols), including but not limited to medical emergencies.

*Emergency medical condition as defined - This is a medical condition which is of sudden and unexpected onset of a health condition that requires immediate medical and/or surgical treatment, where failure to provide this treatment would result in impairment of bodily functions, serious and lasting dysfunc-tion of a bodily organ or part, or would place the person’s life in serious jeopardy. In the case of such an emergency medical condition, the Society must be informed on the first business day following the date of such admission or treatment.

**DTPs - Certain conditions cannot be classified as a PMB condition on their own. To be classified as a PMB condition, the condition must be treated in a specific way in accordance with set protocols. This is known as Diagnosis and Treatment Pairs (DTPs). Only when all the DTP criteria, as per the reg-ulations, are met will claims for the treatment of the relevant condition be classified as a PMB.

Who are the Society’s Designated Service Providers for PMBs, and why should I use them?Although PMBs must be funded in full by medical schemes, the Medical Schemes Act does allow schemes to use certain meas-ures to manage the financial risk associated with the unpredictable health needs of their members such as the use of Designated Service Providers (DSPs).

DSPs are health care providers that have been selected by the Society to provide its members with diagnosis, treatment and care in respect of one or more of the PMB conditions. it is extremely important that you understand the use of DSPs so that you do not end up facing co-payments. The Society’s DSPs are:

• All public hospitals, Dis-Chem Pharmacies, Dis-Chem Direct, Lime

Acres Pharmacy, Premier Mine Hospital Dispensary in Cullinan, the

Namaqualand Pharmacy in Springbok and Dr HA Burger in Spring-

bok for the supply of medicine;

• er 24 – emergency Transport Service Provider; and

• iCON – independent Clinical Oncology Network (Pty) Ltd. All oncol-

ogy related consultation and treatment benefits will be subject to

the iCON protocols and members are reminded that all oncology

medicine must be obtained from Dis-Chem Direct as advised on

page 26. Should an iCON provider not be used, benefits will be

limited to 75% of the consultation cost.

PM

Bs



You have to use these DSPs to receive PMB benefits, otherwise co-payments*** as per the Society’s benefit structure will apply.

***A co-payment is the amount of money or the portion of the account that the Society may require you to pay from your own pocket. This could be either a percentage of the fee, a fixed fee or the difference between the tariff charged by the service provider (non-DSP) that attended to you and the benefit pro-vided by the Society in terms of its Rules.

How do I register for PMBs?Members or service providers may contact the Society’s Claims Department on 053 807 3111 (Option 1) and inform the agent of their request to register for a PMB condition. The Society’s agent will then e-mail or fax the PMB request/application form to the member/service provider for completion.

This form must be completed by the member/service provider and returned by fax to 0866 368 923 or e-mail [email protected]. The Society will then inform the member/service provider of the outcome of their application for registration.

What if circumstances force me to use a non-DSP?if circumstances force you to obtain medical treatment from a non-DSP for the treatment of a PMB condition (in other words invol-untarily as in the case of an emergency medical condition), the Society will pay for the costs of your treatment, diagnosis and care in full. This may occur when:

• the required service from the list of DSPs listed above is not

readily available,

• an emergency medical condition as defined above occurs, or

• there is no DSP within reasonable proximity to where you are when

the emergency occurs.

Please note the Society retains the right to move the patient to an appropriate facility once the patient has been stabilised if additional treatment and care is required.

if, however, a beneficiary voluntarily obtains diagnosis, treatment and/or care in respect of a PMB from a provider other than a DSP, the benefit payable in respect of such service is subject to such benefit limitations as are normally applicable in terms of the rules of the Society. it is generally accepted that pre-authorised treatment of a medical condition in a private hospital is voluntary and normal co-pay-ments will apply regardless of whether PMBs apply.



Why does the Society need ICD-10 codes on the invoice from the service provider?iCD-10 codes provide accurate and specific information regarding the condition that you have been diagnosed with and treated for and should be provided by your service provider on the invoice rendered for the service provided. These codes help the Society to determine what benefits you are entitled to receive and how these benefits must be paid. This becomes very important when you are claiming for the treatment of a PMB condition as the code allows the Society to accu-rately identify the PMB condition. if the PMB condition is treated by one of the DSPs listed above, the account will be paid in full by the Society with no member co-payments. iCD-10 codes therefore ensure that the correct benefit allocation is made. Should you feel an error has been made in assessing your claim, you may follow the process below to query the account.

How do I query an account that I believe should be a PMB?Should you believe that your claim for treatment complies with the PMB requirements as set out above, but you did not receive PMB benefits and you wish to have your claim reviewed, please contact the Society’s Claims Department on tel 053 807 3111 (option 1) or lodge a query by emailing [email protected].

Please ensure that you receive a reference number relating to your query. if your query is not satisfactorily resolved within 14 working days, you may appeal in writing (by letter or e-mail) to the Principal Officer.

Where can I get more information about PMBs?A full list of the PMB conditions can be accessed on the Council for Medical Schemes website (www.medicalschemes.com) as well as regular publications and updates on this subject. A link to the Council for Medical Schemes website is also available on the Society’s website (www.dbbs.co.za).

Please contact the Society if you are unsure about any issues relating to PMBs and associated claims.

PM

Bs

• What are Network Hospitals, and why should i use them?

• How are benefits calculated?

• How will my service providers be paid?

• What is the Scheme rate?

• What is pre-authorisation, and when do i need it?

• How do i obtain pre-authorisation?

• What hospitalisation benefits am i covered for?

• How do benefits for day procedures work?

• How can i minimise costs not covered by the Society if i need to have an operation?

• What if the procedure can be done in the doctor’s rooms?

BeNeFiTS: Hospitalisation benefits>>

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BeNeFiTS: Hospitalisation benefits


What are Network Hospitals, and why should I use them?A Network Hospital is a preferred service provider with which the Society has negotiated agreed rates. Members using such hospitals will therefore not be liable for co-payments and the hospitalisation accounts will be paid in full, except where co-payments are noted (for diagnostic arthroscopy, for example). Members are encouraged to always make use of Network Hospitals, as failure to do so will result in the member being liable for co-payments. Please refer to the list of Network Hospitals on page 58.

Please also note that the agreed rates only relate to hospitali-sation - co-payments may be applicable to charges levied by other service providers in hospital.

How are benefits calculated?Benefits are calculated according to the De Beers Benefit Society reference Price List (SrPL). The National Health reference Price List (NHrPL) was an industry agreed price list for medical services pub-lished by the National Department of Health up to 2006 at which point it was found to be anti-competitive and outlawed. Aligned to medical

aid industry practice the Society adopted its own reference price list, the SrPL, which is based on the NHrPL as it existed until 2006, but adjusted annually to take account of inflation and other changes.

How will my service providers be paid?in cases where service providers charge the SrPL rate, the Society will pay the service provider directly and in full (if there are any co-pay-ments due, these will be collected via the member’s salary/pension subject to credit limits).

Where service providers charge in excess of the SrPL, the Society will automatically refund the member the Society’s benefit liability and the member needs to settle the account directly with the service provider. The reason for doing this is to protect members from automatically being charged co-payments on excessive accounts levied by service providers, thus denying such members the opportunity to discuss the matter with the service provider.

Members can instruct the Society to always only pay the SrPL and to not pay the provider in full under any circumstances. if a member elects to make use of this system then the member will have to pay all co-payments at point-of-sale at all times.

What is the Scheme Rate?The Scheme rate means the rate at which the Society pays benefits to all service providers for services rendered in Network Hospitals

Hospitalisation

benefits



and for defined in-room procedures. The Scheme rate is limited to 165% of the SrPL rate where these services have been provided in an authorised Network Hospital and you have received pre-authorisation for any booked procedure. Members will be liable for any amount by which the professional fees exceed 165% of the SrPL even if it is a PMB (note that only treatment in State Hospitals (DSP) will not attract co-payments). Where a non-Network Hospital is used voluntarily, the SrPL rate will apply and co-payments are likely to apply, depending on the rate charged by the service providers.

Where certain procedures (for example, circumcisions, vasectomies, colonoscopies and gastroscopies) are performed in the doctor’s rooms in lieu of a hospital admission (see page 38), these proce-dures will also be funded at the Scheme rate.

What is pre-authorisation, and when do I need it?Pre-authorisation means obtaining prior approval, for a benefit in terms of the rules, of any planned admission to a hospital, planned procedures or other benefits as defined in the benefits table. All pre-authorisations must be obtained notlessthan72hourspriortothebenefitbeingaccessed (in other words, hospital admissions, CT scan or wheelchairs). This includes any associated treatment or procedures performed during hospitalisation. in the case of emergency hospitalisation, the Society must be notified within 24 hours or on the first working day after such admission or treatment

was initiated. in non-emergency cases or other cases where the required pre-authorisation was not obtained, no benefit will apply.

How do I obtain pre-authorisation?Obtain pre-authorisat ion for any planned admissions to hospital or other benefits as defined in the benefits table by con-tacting the Society’s hospital pre-authorisation department between 09h00 and 15h00 toll-free at 0800 111 669 (rSA members) or e-mail [email protected].

Non–rSA based members residents can call +27 53 807 3111 (Option 3) or e-mail [email protected] at least 72 hours prior to admission. in the event of an emergency, the Society must be notified within 24 hours after the event or the next working day if it falls on a weekend or public holiday. The Society has a preferred provider arrangement with a number of hospitals throughout South Africa. These hospitals are known as ‘Network Hospitals’ (see the List of Network Hospitals on page 58).

What hospitalisation benefits am I covered for?Hospitalisation benefits in a Network Hospital – if you have a pro-cedure performed in a Network Hospital for which you have obtained pre-authorisation from the Society, no co-payments will be due by you in respect of the hospital account other than in cases where benefits only apply for the procedure if performed out-of-hospital (for example in the doctor’s consultation rooms) as noted elsewhere. The Society



will also settle accounts directly and in full from your service providers, for example surgeon, anaesthetist etc. unless it exceeds the Scheme rate as noted on page 15.

Hospitalisation benefits in a non-Network Hospital – if you have a procedure performed in a non-Network Hospital for which you have obtained pre-authorisation from the Society, your account may not be paid in full (depending on the level at which you are charged) and co-payments may be incurred. in addition, claims from service providers (i.e. specialists and surgeons) will not be funded at the Scheme rate but at the lower, normal SrPL rate which may lead to co-payments being due by you depending on what rate such service providers choose to charge.

Hospitalisation benefits in other facilities – Pre-authorised admis-sions to day clinics, psychiatric hospitals and step-down facilities and other forms of care are not impacted on by the above restriction regarding admissions to non-Network Hospitals. Co-payments may however apply in certain circumstances.

Other service providers used while hospitalised (for example, surgeons and specialists) – Please remember that when you are in hospital, there are also other costs to consider apart from the actual hospitalisation costs, for example, service charges by special-ists, physiotherapists, dieticians, etc. it is your responsibility to check what the specialists’ charges will be and what portion will be covered by the Society. if the service providers charge in excess of the SrPL

tariffs, the Society will apply the Scheme rate to these claims only if the hospitalisation has been pre-authorised at a Network Hospital. Any charges higher than the Scheme rate will be for the member’s account even if hospitalisation had been pre-authorised and was in a Network Hospital. Where a non-network hospital has been author-ised, the rate at which service providers will be reimbursed will be at the SrPL rate.

How do benefits for day procedures work?A same-day hospital admission, if authorised as such, will qualify for benefits if the admission and discharge occur on the same day without any overnight stay. Should an overnight stay subsequently be required, the difference in cost will be for the member‘s account.

if an admission to a non-Network Hospital subsequently results in an overnight stay, the entire account will change to the SrPL rate and the member will be liable for any difference in costs between that charged for a day admission and the actual final account rendered, based on the actual time and date of discharge.

Members are encouraged to ensure that, if they are admitted for a day procedure, their doctor performs the procedure early enough in the day to ensure that an overnight stay is not required for recovery from the anaesthetic administered.

Hospitalisation

benefits



How can I minimise costs not covered by the Society if I need to have an operation?Find out from your referring doctor or specialist what service providers will be involved in your case, for example:

• the surgeon(s)

• the anaesthetist

• any doctors or specialists assisting the surgeon

• follow-up treatments in hospital, such as physiotherapy, pathology

tests, x-rays, etc.

Ask the doctors/service providers what they will charge in compar-ison with the SrPL tariffs. You can contact the Society on 053 807 3111 (Option 1) for information on SrPL tariffs. Negotiate with all your service providers to charge the SrPL tariff if they quote a higher rate. if you are not successful, consider using an alternative specialist as you will be liable for all the additional costs over and above the SrPL tariff.

What if the procedure can be done in the doctor’s rooms?Certain medical procedures can be performed in a doctor’s consulta-tion rooms and it is therefore not necessary for members to endure the inconvenience of being admitted to hospital. Members would need to request authorisation for indicated procedures and the Society would then provide benefit up to the Scheme rate, thus reducing the possi-bility of member co-payments. No authorisation is required for minor (non-booked) in-rooms procedures, but please contact the Socie-ty’s hospital pre-authorisation department if you require clarification.

Co-payments of r1,500 apply to gastroscopies, colonoscopies, cir-cumcisions, male sterilisations and intravitreal injections that are performed in-hospital as it is standard practice for these proce-dures to be performed in the doctor’s consultation rooms. When the member requests authorisation for a planned procedure, the Society will indicate to the member (when providing written confirmation of the authorisation) whether a co-payment will be payable or not.


What must I do in an emergency?You and your registered dependants who are resident in South Africa (the rSA), and qualifying members resident in Botswana and Namibia (subject to the conditions outlined above), have unlimited access to emergency medical transportation 24 hours a day, provided that this is pre-authorised by er24.

Simply call

084 124(RSA residents)

FOR QUALIFYING BOTSWANA OR NAMIBIAN RESIDENTS CALL

+27 10 205 3000Services offered by ER24:

• 24-hour access to the er24 emergency Call Centre

• Dispatch of emergency response

• Medical transportation by ambulance or aircraft

• Authorised inter-hospital transfers• What must i do in an emergency?

• Will emergency admissions to hospital be covered?

• What if the emergency occurs outside South Africa?

05BeNeFiTS: emergency benefits>>

Em

ergency

benefits

BeNeFiTS: emergency benefits


in addition to emergency transportation, you can also obtain emergency medical advice and assistance from er 24. er24’s operators will guide you through a medical crisis sit-uation, provide emergency advice and organise for you to receive the support you need .This service is available on a 24 hour basis.

Will emergency admissions to hospital be covered?The Society will cover the hospital and specialist charges for emer-gency* hospital admissions in the rSA and for qualifying members resident in Botswana and Namibia as outlined above at cost, provided that the Society is informed of the admission on the next working day.

What if the emergency occurs outside South Africa?Please note that er24 coverage will only apply to emergencies in the rSA and for qualifying members resident in Botswana and Namibia as outlined above. if you are an rSA citizen, resident in the rSA and are travelling on holiday to Botswana or Namibia or, for that matter, to any other country in the world, you will NOT be covered by er24 or by the Society and you are therefore encouraged to arrange appropriate travel insurance including medical evacuation in good time before you depart.

*Definition of a medical emergency: The sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide such medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunc-tion of a bodily organ or part, or would place the patient’s life in serious danger.


How are medicine benefits provided by the Society?in short, the benefit for medicine is calculated as follows:

CHrONiC MeDiCiNe

A 100% benefit applies to chronic medicines for listed conditons, limited to the lesser of either the Therapeutic reference Pricing (Formulary) (TrP) or the Generic reference Pricing (GrP) value applicable to the medicine on condition that the medicine is in the ‘medicine basket’ for the authorised disease treated and is obtained from one of the Society’s DSPs.

ACuTe MeDiCiNe

A 70% benefit at Single exit Price (SeP plus a maximum 29.64% mark-up (including VAT) applies to acute medicines. This is limited to the GrP value applicable to the medicine.

What tools are used by the Society to manage medicine benefits?The Society makes use of a number of industry implemented tools to manage medicine benefits. These tools are explained in detail below.

• How are medicine benefits provided by the Society?

• What tools are used by the Society to manage medicine benefits?

• How can i obtain acute medicine?

• What chronic conditions are covered by the Society?

• How do i obtain my chronic medicine?

• How am i required to obtain oncology medicine?

• What if i need an additional supply of chronic medicine due to travelling?

• What else do i need to know about chronic medicines?

06 BeNeFiTS: Medicine benefits>>

Med

icine b

enefits

BeNeFiTS: Medicine benefits


Medicine basket

The medicine basket is an extensive list of medicines available to treat a specific condition and to which Society benefits apply. The Society makes use of these medicine baskets so that the member/doctor has a range of medicines available to treat a specific disease. it is there-fore not necessary for the doctor to change your registered chronic medicine with the Society if he/she wants to treat you with a different medicine for the same underlying condition. in essence you remain registered, for example, for Hypertension as a chronic condition and then chronic medicine benefits will be provided for different medicines within the basket until the doctor stabilises your condition on a specific medicine from the medicine basket.

However, if the prescribed medicine is not included in the Society’s medicine basket, the Society will not provide any chronic medicine benefit for that specific medicine for the registered disease.

it should also be noted that the GrP and TrP is still applied to the medicine although the medicine is in the Society’s medicine basket.

Generic Reference Pricing (GRP)

GrP is a tool used in the healthcare industry to promote the effective utilisation of medicine benefits while ensuring patients have contin-ued access to high quality medical care. The GrP model calculates the average price of selected products that are generically equivalent to the original patented product that have been grouped together

(generically equivalent products are those that are identical in terms of active ingredient and strength to the original patented product). This selected generically-equivalent group of products on which the average price is based is reviewed continuously by a panel of clinical experts to ensure the appropriateness thereof as well as the availa-bility of products contained within this reference price group. GrP applies to all medicine where a Medicine Control Council (MCC) approved generic equivalent medicine is available.

Members claiming for medicines priced above the GrP will be subject to an additional co-payment calculated as the difference between the claimed amount and the GrP.

Please note that if you or your doctor insists on original brand-name medicine and not a generic equivalent (subject to GrP), or do not want to change your medicine to one that is within the Formulary, you will be liable for a co-payment.

Medicine prices change and new products are introduced contin-uously. Members should therefore note that the GrP values are updated on a monthly basis and therefore may result in a medicine that was within the GrP limit in one month potentially exceeding it in the next month and therefore attracting a co-payment. it is therefore essential to communicate with the pharmacist or operator (in the case of Dis-Chem Direct) and to ask if there will be any co-payments on the medicines requested for each month.



Therapeutic Reference Pricing: Society Medicine Formulary (Formulary)

A Formulary is a list of medicines compiled by clinical experts, based on evidence-based medicine showing the effectiveness of these med-icines in treating a particular disease whilst remaining cost effective. The Society will pay the full cost of such medicines as listed in its For-mulary to treat a particular chronic disease.

The Society has a comprehensive Formulary in place for all the chronic conditions indicated on page 24. The Society publishes the approved Formulary list on its website www.dbbs.co.za under the tab “Service Provider Area”. Alternatively a member or service provider can contact the Society on tel 053 807 3111 (Option 1) to obtain the required information regarding chronic conditions for which the Society has a Formulary in place.

Summary

in view of the above and in summary it should therefore be noted that there will be no co-payment on any chronic medicine used in the treatment of chronic conditions listed on page 24-25, provided that the following criteria are all met:

• You have been registered on the Society’s Disease Management

Programme for the particular chronic disease, thus authorising

chronic medicine benefits. if you do not register on the Disease

Management Programme, the cost of the medicine will be deducted

from your acute medicine benefits and you will be liable for a

30% co-payment;

• You obtain your chronic medicine from a DSP;

• The prescribed medicine is within the Society’s Formulary/TrP;

• The medicine is within the GrP limits; and

• You have not exhausted your chronic medicine benefits for

non-PMB conditions.

How can I obtain acute medicine?You can obtain your acute medicine from any pharmacy, but the Society has an agreement with its DSPs to ensure that a fixed mark-up is charged that would not result in an additional levy above the 30% acute co-payment. So if you live in the vicinity of any Dis-Chem Phar-macy, Lime Acres Pharmacy, Premier Mine Hospital Dispensary in Cullinan, or the Namaqualand Pharmacy in Springbok, you may collect your acute medicine from these pharmacies or directly from Dr HA Burger in Springbok. if this is not convenient, you may also collect your acute medicine from any other retail pharmacy in South Africa. if you choose this option, it is important that you check that the pharmacy charges the current SeP with a professional fee added to a maximum of 29.64% (including VAT), limited to a maximum of r29.64 per item dispensed. if a higher pricing structure applies, you will have to pay the difference. This is in addition to the normal 30% co-payment due for acute medicines in terms of the rules of the Society.

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How does the Over-the-Counter (OTC) medicine benefit work?OTC (Patient Advised Therapy (PAT)) medicines form part of the annual acute medicine limit (see page 34 for details). Should a member consult with a pharmacist, the pharmacist may prescribe medicine to treat particular conditions without the need for the member to consult a doctor and obtain a formal doctor’s prescription. For example, should a member or his dependant experience cold and flu symptoms, they can go directly to the pharmacy and communicate their symptoms to the pharmacist. The pharmacist may then dispense medicines to treat

those symptoms, within his scope of practice, without a doctor’s pre-scription up to the value indicated in the benefit table.

Please note this benefit is not intended to provide members the opportunity to obtain certain items such as general pain killers or cough mixture, but rather to treat particular and specific ailments as they occur that do not require a doctor’s consultation.

What chronic conditions are covered by the Society?

The PMB chronic condition Chronic Disease List (CDL) includes the following (CDL PMBs):

1. Addison’s Disease

2. Asthma

3. Bipolar Mood Disorder

4. Bronchiectasis

5. Cardiac Failure

6. Cardiomyopathy Disease

7. Chronic Obstructive Pulmonary Disease

8. Chronic renal Disease

9. Coronary Artery Disease

10. Crohn’s Disease

11. Diabetes insipidus*

12. Diabetes Mellitus Type 1 and 2

13. Dysrhythmias

14. epilepsy

15. Glaucoma

16. Haemophilia*

17. HiV/AiDS

18. Hyperlipidaemia

19. Hypertension

20. Hypothyroidism

21. Multiple Sclerosis*

22. Parkinson’s Disease

23. rheumatoid Arthritis

24. Schizophrenia

25. Systemic Lupus erythromatosis

26. ulcerative Colitis

• Medical conditions marked * will only qualify for bene-fits under specific circumstances. Please contact the Society for details in this regard.



in addition to the chronic conditions listed on the left-hand side, the Society will also cover the following conditions (which do not qualify for PMBs and are subject to the annual chronic medicine limit) (non-CDL Chronic):

1. Acne*

2. Allergic rhinitis*

3. Alzheimers Disease*

4. Ankylosing Spondylitis

5. Benign Prostatic Hypertrophy

6. Cushing’s Disease §

7. Cystic Fibrosis*

8. Deep Vein Thrombosis

9. Gastro-Oesophageal reflux Disorder*

10. Gout*

11. Hyperpara-thyroidism §

12. Hyperthyroidism §

13. Hypoparathyroidism §

14. incontinence

15. Major Depression §

16. Ménière’s Disease*

17. Menopausal and Peri-menopausal Disorders §

18. Motor Neuron Disease

19. Myasthenia Gravis

20. Osteoarthritis

21. Osteoporosis*

22. Paget’s Disease

23. Paraplegia, Quadriplegia* §

24. Peripheral Vascular Disease §

25. Pituitary Adenomas §

26. Psoriasis

27. Pulmonary interstitial Fibrosis

28. Stroke / Cerebro-vascular Accident §

29. Systemic Connective Tissue Disorders (incl. Scleroderma & Dermatomyositis)

30. Attention Deficit Hyperactivity Disorder

• Medical conditions marked § may attract prescribed minimum benefit entitlement in terms of the diagnosis and treatment pairs as per Annexure A to the Regulations of the Medical Schemes Act.

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How do I obtain my chronic medicine?Once you have been registered on the Society’s Disease Manage-ment Programme for your particular chronic condition and the proper authorisation has been granted for your medicine, you may submit your prescription to your pharmacy DSP and they will dispense your chronic medicine. Society members can collect their chronic medi-cine from one of the following DSPs: any of the Dis-Chem Pharmacies nationwide, Lime Acres Pharmacy, Premier Mine Hospital Dispensary in Cullinan, the Namaqualand Pharmacy in Springbok or directly from Dr HA Burger in Springbok.

if collection is not possible, or if you do not have a DSP phar-macy where you live, your chronic medicine will be delivered to you free of charge by Dis-Chem Direct, via courier. in such a case you must fax your prescription to 086 529 0228 or email it to [email protected]. You are required by law to send the origi-nal prescription to the pharmacy; in this case Dis-Chem Direct at PO Box 597, Menlyn, 0063.

Please note that submission of your prescription does not automatically instruct Dis-Chem Direct to forward your chronic medicine. You have to give them specific instruc-tions via the call centre 086 122 6668 or by fax or e-mail [email protected] detailing each item required and providing your preferred delivery method, address, member-ship number and contact telephone numbers.

remember that if you make use of the courier pharmacy (Dis-Chem Direct), you need to re-order your chronic medicine at least 10 working days before your current supply is depleted. Chronicmedicineisnotautomaticallydispensed.

in the event that you obtain your chronic medicine from any other source than that listed above, (also known as out-of-network), this will carry a co-payment of 30% plus the difference between the supplier charges and the contracted price that the Society has with its DSPs and any GrP/TrP co-payment, if relevant.

How am I required to obtain oncology medicine?All oncology medicine must also be obtained from Dis-Chem Direct by your service provider or by you, as appropriate, and comply with normal GrP and Formulary rules.

What if I need an additional supply of chronic medicine due to travelling?A DSP may dispense a two-month supply of chronic medicine with no special authorisation required, at any one time (same date of supply) to any Society beneficiary who is going to be travelling in areas out of reach of DSPs. This is monitored to avoid abuse.

Should a beneficiary be travelling for an extended period of time outside South Africa, a second supply may be authorised for supply at the same time (four months maximum), under the following conditions:



• The member is required to request authority from the Society and to

provide the travel documentation supporting such application (such

authority can be obtained by e-mailing [email protected] or

by calling the call centre on 053-807-3111 and selecting option

1); and

• The DSP pharmacy manager (either of a DSP pharmacy or Dis-

Chem Direct) must confirm with the Society’s Claims Supervisor

that such authority has been granted before the electronic claim is

processed.

Please note that the required contact details have been com-municated to the DSP pharmacies to obtain this confirmation.

What else do I need to know about chronic medicines?• All chronic medicine prescriptions are only valid for six months from

the date of issue. Members must obtain a new prescription before

this period expires. You can refer to the label on the medicine which

would indicate how many refills have been dispensed.

• Homeopathic medicine does not qualify for chronic

medicine benefits.

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BeNeFiTS: Day-to-day benefits


What day-to-day benefits are covered by the Society?in addition to the major medical benefits described in Sections 3 to 6 above, the Society offers a variety of day-to-day benefits.

Typically these benefits include (but are not limited to) doctors’ consultations, X-rays, dentist visits and associated treatment, medicines for day-to-day illnesses and optometry benefits.

These day-to-day benefits are detailed in the next section.

• What day-to-day benefits are covered by the Society?

07 BeNeFiTS: Day-to-day benefits>>

BeNeFiTS: Day-to-day benefits


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Important notes• The Society’s financial year is from 1 January to 31 December.

unless otherwise specified, the benefits described in this guide

apply to this one-year period. Benefits are not transferable from one

financial year to another, from one category to another, or from one

beneficiary to another.

• Waiting periods and late joiner penalties may apply to new

members. For more information in this regard, please refer to the

Society’s rules or contact the Society.

• important notes

• Prescribed Minimum Benefits

• Consultations (out-of-hospital)

• Diagnostic testing

• Oncology

• Medicine

• Dental

• Optometry

• Medical equipment

• Care not in-hospital

• in-hospital

• emergency transport

• Other

• What benefits are excluded by the Society?

• To what extent are benefits limited by the Society?

08 BeNeFiTS: Benefit details for 2014>>

BeNeFiTS: Benefit details for 2014


The benefits listed below only apply to the Society’s area of operation as defined on page 45.

NO BENEFIT DESCRIPTION NOTES RE EXTENT OF BENEFIT/ ANNUAL LIMIT/ CONDITIONS

PRESCRIBED MINIMUM BENEFITS

1. Statutory PMBs • Benefit is 100% of the cost of the PMB treatment.

• For all services relating to PMBs, please ensure that you make use of a Designated Service Provider (DSP), where it exists, otherwise co-payments will apply. Please note that the State hospital facilities are the only DSPs that provide both hospital and doctor/specialist services for which benefits will not be limited for PMB-related procedures. Members are advised that the doctors/specialists providing services in Network Hospitals are not DSPs and co-payments will apply where excessive charges are levied by these providers when performing a PMB procedure. To avoid any co-payment being levied for a voluntary PMB procedure in hospital you should only make use of a State hospital facility for the in-hospital treatment.

• Benefits are subject to the provisions set out in paragraph 2 of Annexure B of the rules and shall, insofar as may be applicable, override any restrictions or limitations imposed in respect of benefits set out below.

• unlimited.

CONSULTATIONS (OUT-OF-HOSPITAL)

2. General Practitioners (GPs), Specialists and registered Homeopaths

• Benefit is 90% of Society reference Price List (SrPL).

• Combined GP, specialist and homeopath limit of 15 consultations per beneficiary.

• For elective non-emergency afterhours consultations, the benefit shall be limited to the SrPL rate for a normal consultation. See page 52 on how to avoid additional co-payments in this regard.

• Doctors’ house calls will be paid at normal consultation rates unless clinically assessed to be a medical emergency.

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3. General Practitioner and Specialist in-rooms procedures

• Benefit is 100% of SrPL.

• The following in-rooms procedures must be pre-authorised by the hospital pre-authorisation department and will be reimbursed at 100% of the Scheme rate:

- Gastroscopy, Colonoscopy, Vasectomy, Circumcision and intravitreal injection

• unlimited but subject to the 15 consultations per beneficiary.

4. Nursing Practitioner • Benefit is 100% of SrPL unlimited.

DIAGNOSTIC TESTING

5. Pathology • Benefit is 90% of SrPL out-of-hospital.

• Subject to request by medical practitioner.

6. radiology • Benefit is 90% of SrPL out-of-hospital.

• Subject to request by medical practitioner.

7. CT and Mri scans

(In- and out-of-Hospital)

• Benefit is100% of SrPL.

• Limited to three scans per beneficiary per year excluding oncology planning scans.

• including radio isotope scan.

• Subject to managed care protocols and pre-authorisation from hospital pre-authorisation department.

8. Bone density scans • Benefit is 90% of SrPL out-of-hospital.

• No benefit in-hospital.




9. PeT Scans • Benefit is100% of SrPL.

• Accrues to oncology benefit limit.

• Subject to managed care protocols and pre-authorisation from hospital pre-authorisation department.

ONCOLOGY

10. Treatment in and out of hospital

• Benefit is 100% of SrPL or Scheme rate in- and Out-of-hospital at the DSP (iCON provider)

• Benefit limited to r197 450 per beneficiary.

• including all PeT and related CT planning scans subject to overall limit.

• Managed care protocols apply and pre-authorisation is required from hospital pre-authorisation department and should an iCON provider not be used, the benefit will be limited to 75% of the consultation cost.

• All parenteral medicine for oncology treatment must be obtained from Dis-Chem Direct and comply with normal GrP and Formulary rules.

MEDICINE

Please note:

1. Pharmacists are legally obliged to dispense generic medicine, unless expressly prohibited in writing by your doctor on the prescription issued by him/her, in which case you remain liable for the additional expense as outlined below.

2. The Generic reference Price (GrP) will be applied to both acute and chronic medicine and in cases where medicine is obtained at a value above this reference price, the additional cost will be the beneficiary’s liability. refer to page 22 for more information.

3. The Society Medicine Formulary (the Formulary) is applicable to all chronic conditions, CDL and non-CDL conditions, where a Formulary

has been implemented. Where a beneficiary elects not to make use of a Formulary drug, a co-payment will be levied equivalent to the difference between the lowest of the reference price (TrP) or GrP and the cost of the drug obtained.

4. in circumstances where a beneficiary is due to travel outside of South Africa, the quantity of medicine benefits provided may be increased to two additional months’ supply, subject to pre-approval by the Society.

5. Where a member makes use of Dis-Chem Direct to supply their chronic medicine, the original prescription must be posted (registered post preferably) to Dis-Chem. Dis-Chem may refuse to supply if they are not in possession of the original prescription.

See page 26 for more detail.

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11. Acute medicine • Benefit is 70% of the GrP, limited to r3 250 per beneficiary per year.

• includes prescribed homeopathic medicine.

• Benefit for OTC (Patient Advised Therapy) limited to r145 per prescription and subject to the acute medicine limit of r3 250 per beneficiary.

• See page 24 for more detail.

12. Chronic medicine

(CDL PMB and listed non-CDL chronic)

• Benefit is 100% of the lesser of the GrP or TrP provided it is dispensed by a DSP (see page 24-25 for a list).

• Benefit is limited to r28 800 for CDL and non-CDLs (cumulative) but remains unlimited for all PMBs once the chronic medicine limit is reached.

• Benefit is 70% of the lesser of the GrP or TrP if a non-DSP (any supplier not on the DSP list) is voluntarily used.

• Subject to Society approval.

• Note: The overall cumulative benefit limit for both CDL PMB and listed non-CDL chronic medicine (see page 24-25) is r28 800 per beneficiary per year. if this limit is reached before year-end, the CDL PMB chronic medicine will continue to be covered in terms of PMB protocols, provided a DSP is used to obtain the medicine.

DENTAL

13. Conservative dentistry • Benefit is 90% of SrPL.

• includes preventative and diagnostic consultations, cleaning, fillings, extractions and x-rays.

• Managed care protocols apply and pre-authorisation is required in respect for elective procedures where general anaesthesia is required for dentistry on children under the age of nine (limited to one admission per year), the removal of impacted wisdom teeth, apicectomies, removal of teeth and roots or exposure of teeth for orthodontic reasons.

• No limit applies in respect of dentistry required as a result of trauma.




14. Specialised dentistry • Benefit is 90% of SrPL.

• Limited to r7 040 per beneficiary.

• includes crowns, dentures, bridges, implants and periodontal treatment.

• Managed care protocols and pre-authorisation apply where hospitalisation is required.

15. Orthodontic treatment • Benefit is 75% of SrPL.

• Limited to r17 330 per beneficiary per lifetime.

• Note: Benefits are not provided for treatment commencing after a beneficiary’s 18th birthday.

• Pre-authorisation is required.

OPTOMETRY

16. eye test, single vision-, bi-focal-, multi-focal lenses including contact lenses, frames and rimless fittings

• Benefit is limited to 90% of the tariffs as per the Optical Assist Pricing Guide.

• Overall limit of r3 710 per beneficiary with a sub-limit of r1 060 on frames and rimless fittings for every two year cycle.

• Two year cycle for all beneficiaries starts January 2014.

• No liability for repairs to spectacles.

17. intra-ocular lenses • Benefit is 100% of SrPL limited to single vision lenses and to a maximum of r1 680 per lens per lifetime.

• Managed care protocols apply and pre-authorisation is required from hospital pre-authorisation department.

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18. refractive Surgery • Benefit is 50% of SrPL or Scheme rate in and out of hospital.

• Limited to one procedure per eye per lifetime.

• Lenses limited to single vision lenses.

• including but not limited to excimer Laser and eye surgery required for Astigmatism, Hypermetropia, Presbyopia, Myopia and Hypermyopia.

MEDICAL EQUIPMENT

The type of appliance covered by this benefit will be at the discretion of the Society and all repairs to and maintenance of medical equipment is included in the limit set for the particular term of the benefit cycle.

19. external appliances • Benefit is 50% of the cost as approved by the Society.

• Limited to r5 620 per beneficiary per five year cycle from date of first supply.

• includes, but is not limited to, insulin pumps, CPAP machines, orthopedic boots, surgical collars, external breast prosthesis, nebulisers, artificial eyes and hiring of equipment.

• Managed care protocols apply and pre-authorisation is required from the hospital pre-authorisation department.

20. Colostomy bags and catheters

• Benefit is 90% of the cost as approved by the Society.



21. Continuous Oxygen Supply machine rental and/or oxygen







22. external Prosthesis

(such as artificial limbs)


• Limited to r36 940 per beneficiary per five-year cycle from date of first supply.


23. Hearing aids • Benefit is 90% of the cost as approved by the Society.



• No benefit is payable in respect of replacement of hearing aid batteries.

24. Wheelchairs • Benefit is 90% of the cost as approved by the Society.


• Quadriplegics and Paraplegics ONLY: 90% Benefit limited to r21 200 per five year cycle from date of first supply.


• No benefit for motorised carts / tricycles other than motorised wheelchairs in appropriate cases.

CARE NOT IN-HOSPITAL

25. Audiology, Chiropody, Podiatry, Acupuncture, Dietician services, Occupational and Speech Therapy


• Combined limit of r2 350 per beneficiary.

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26. Physiotherapy including Biokinetics and Chiropractic Services


• Combined limit of r7 040 per beneficiary.

27. Private Nursing • Benefit is 90% of SrPL.


• Pre-authorisation is required from the hospital pre-authorisation department and the provider must be a registered nurse.

28. Psychological and psychiatric treatment not in hospital



IN-HOSPITAL

29. Hospitalisation

(Including Day Cases, In-rooms procedures in lieu of hospitalisation and alternative facilities)

• Benefit is 100% of SrPL or Scheme rate where a Network Hospital has been authorised.

• Subject to pre-authorisation and managed care protocols in a facility and manner which the Society deems appropriate.

• Pre-authorisation is required from the hospital pre-authorisation department at least 72 hours prior to admission.

• A co-payment of r1 500 per procedure authorised will apply to all Colonoscopies, Gastroscopies, Circumcisions, Vasectomies and intravireal injections authorised to take place in-hospital. Where two or more of the above procedures are performed simultaneously in-hospital, only one co-payment will be levied.

- No co-payment will be applied to the above procedures if pre-authorised out of hospital.

• A co-payment of r1 500 will apply to all arthroscopic and laparoscopic procedures performed for diagnostic purposes.

• The following laparoscopic procedures may be authorised in terms of the Society’s protocols but will be subject to a capped overall benefit limit (inclusive of all hospital and service provider costs):

- Laparoscopic Appendectomy (r15 000), Laparoscopic assisted Vaginal Hysterectomy (r22 000) and Laparoscopic unilateral inguinal Hernia (r10 000) Managed Care Protocols take precedent when determining pre-authorisation.




30. Professional fees charged by service providers in hospital

• Benefit is 100% of SrPL or Scheme rate where a Network Hospital has been authorised.

• Where a service provider charges more than the Scheme rate, the member will be liable for the difference even if it is a PMB. Members are to take note that all public hospitals are the only DSPs where the provider’s costs are unlimited for PMB pre-authorised procedures.

31. Maxilla facial and oral surgery


• Pre-authorisation is required from hospital pre-authorisation department and managed care protocols will apply.

• This excludes surgery in preparation for Osseo-integrated implants and Orthognatic surgery.

32. Blood transfusions • Benefit is 100% of SrPL unlimited.

33. Psychiatric hospitalisation • Benefit is 100% of SrPL or Scheme rate.

• Limited to 21 days per beneficiary provided that the treatment of PMB conditions are limited as per year Annexure A of the regulations.

• including the treatment of mental disorders and alcohol and drug dependency.

• Pre-authorisation is required from hospital pre-authorisation department and managed care protocols will apply.

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34. internal prosthesis

(such as plates, screws, stents and pacemakers, etc.)


• Limited to an overall benefit of r34 980 per beneficiary (inclusive of bone cement, cages, screws, plates, coronary and vascular stents, pacemakers, aortic and valve replacements).

• Managed care protocols will apply and pre-authorisation is required from hospital pre-authorisation department.

• The overall annual limit is cumulative for all the sub-limits below:

- Joint replacements - r34 980;

- Spinal prosthesis - r34 980;

- Coronary and vascular stents, pacemakers, aortic and mitral valve replacements - r34 980; and

- Mesh (Gortex and TVT slings) - r10 600.

35. Cochlea implants • Benefit is 100% of SrPL.

• Managed care protocols will apply and pre-authorisation is required from hospital pre-authorisation department.

36. Hospital medicines • Benefit is 100% of SeP.

• TTO (take home medicine) medicine up to a maximum of seven days’ supply.

37. Physiotherapy • Benefit is 100% of SrPL.

38. Pathology • Benefit is 100% of SrPL.

39. radiology • Benefit is 100% of SrPL.

• Pre-authorisation is required from the hospital pre-authorisation department for all Mri, CT and radio isotope scans and limited to 3 scans per year in and out of hospital.

• No benefit for Bone Density scans in hospital.




EMERGENCY TRANSPORT

40. emergency road and air transport

• Benefit is 100% unlimited, subject to pre-authorisation by er24.

• er24 is the DSP for all emergency and ambulance services.

• No benefit for use of any other ambulance services.

• Coverage only in rSA and limited to qualifying residents in Botswana and Namibia subject to conditions as outlined on page 19.

OTHER

41. Dialysis • Benefit is 100% of SrPL or Scheme rate in and out of hospital.

• Applicable to all confirmed PMB cases and managed care protocols will apply.

• Pre-authorisation required from the hospital pre-authorisation department.

42. Organ Transplants, harvesting and immune suppressive medicine

• Benefit is 100% of SrPL or Scheme rate in hospital.

• Applicable to all confirmed PMB cases and managed care protocols will apply.

• Pre-authorisation required from the hospital pre-authorisation department.

43. Corneal Transplants • Benefit is 100% of SPrL or Scheme rate in hospital.

• Graft benefit limited to r10 000 per beneficiary.

• Managed care protocols apply and pre-authorisation required from the hospital pre-authorisation department.

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What benefits are excluded by the Society?except for certain relevant health services covered by the PMBs deliv-ered to beneficiaries in accordance with protocols and formularies used by the Society or its contracted managed care providers, and unless otherwise provided for in the Society’s rules or determined by the Board, expenses incurred in connection with any of the following will not be paid by the Society:

1. expenses incurred by a beneficiary because of wilful self-inflicted

injury, attempted suicide or the excessive use of an intoxicating sub-

stance or drug.

2. expenses arising from injuries sustained as a result of participation

in professional sport.

3. expenses arising from injuries or illness when breaching the law.

4. expenses arising from examinations, treatment and/or operations for

cosmetic purposes, infertility, artificial insemination, impotency and

erectile dysfunction or treatment of an experimental nature or not

published in international evidence based treatment or management

guidelines, and any complication that may arise from such examina-

tions or treatment.

5. expenses (including expenses relating to any PMB) incurred outside

the Area of Operation.

6. expenses incurred by a beneficiary during any waiting period

imposed by the Society in terms of its rules.

7. expenses in respect of the treatment of any learning, marital, social

or family problems.

8. expenses relating to the purchase of:

a. any drug or medicine not registered by the Medicines Control

Council or similar authority; or

b. medicines not registered for treatment of the condition for

which such medicines are obtained and any patent and

household remedies.

9. expenses relating to any contraceptive preparations and devices.

10. expenses relating to services that do not relate to any sickness

condition, including but not limited to examinations for insur-

ance, employment, visas, pilot and driving licenses and school

readiness tests.

11. expenses relating to any reduction mammoplasty.

12. expenses relating to any recuperative or convalescent holidays.

13. expenses relating to any diagnostic preparations and instruments,

soaps, shampoos and other topical applications (of a cosmetic

nature), medicated or otherwise but excluding those intended for

treatment of lice, scabies and other parasitic or fungal infections.

14. expenses relating to any anti-addiction and anti-habit agents.

15. expenses relating to any cosmetic items inclusive of hair-restorers.



16. expenses relating to any sun screening and sun-tanning agents

except those intended for the treatment of skin disorders.

17. expenses relating to any homeopathic and herbal medicines and

remedies not prescribed by a registered homeopath.

18. expenses relating to any food supplements including all patent and

baby foods and special milk preparations.

19. expenses relating to any household bandages, dressings

and diapers.

20. expenses relating to any syringes and needles except those

required for use in the treatment of diabetes.

21. expenses relating to any vitamins, mineral supplements, growth hor-

mones and tonics including but not limited to efamol G and similar

products, stimulants e.g. reactivan, except vitamins e.g. Vitamin B

and probiotics needed in conjunction with antibiotics. However, ben-

efits will be granted for the following:

a. Pre-natal vitamins; and

b. Calcium supplements when prescribed and approved for the

treatment of osteoporosis.

22. expenses relating to any contact lens preparations.

23. expenses relating to any demand prescriptions.

24. expenses relating to any telephone prescriptions, other than for

repeat prescriptions.

25. expenses relating to any telephonic consultations.

26. expenses relating to accommodation and nursing services rendered

in convalescent or old age homes or similar institutions catering

for the aged or chronically ill other than specifically provided for in

the rules.

27. expenses relating to all sunglasses.

28. expenses relating to appointments not kept by a Beneficiary.

29. expenses relating to sleep therapy.

30. expenses relating to an illness of a protracted nature, if the ben-

eficiary, at the request of the Society, fails to consult a specialist

nominated by the Society in consultation with the attending practi-

tioner or fails to act upon the treatment proposed by such specialist.

31. expenses incurred without a pre-authorisation as required by

the rules.

32. expenses relating to:

a. 3D and 4D gestational sonars

b. Angioseal and similar closure devices when performing

coronary angiograms

c. Artificial Discs

d. Genetic testing, unless authorised Gynaecomastia

e. intravascular ultrasound (iVuS) Kyphoplasty Mammoplasty

f. Motorised carts/tricycles, other than motorised wheelchairs in

appropriate cases.

Benefit

details fo

r 2014



g. Mri of the breast

h. Oncotype tests, unless authorised

i. Orthodontic treatment of beneficiaries older than 18 years.

j. Orthognatic surgery

k. rhizotomy, unless authorised

l. Vaccinations against the Human Papillomavirus (HPV) (e.g.

Gardacil® and Cervarix®) Vasovasotomy

33. expenses relating to services which are regarded as not being

medically necessary, provided that a treatment, procedure, supply,

medicine, hospital or specialised centre stay (or part of a hospital or

specialized centre stay) shall be regarded as medically necessary if:

a. The treatment is required to restore the normal function of an

affected limb, organ or system;

b. The treatment is generally accepted as optimal and necessary

for the specific condition and is supplied at an appropriate level

to render safe and adequate care;

c. The treatment is not rendered for the convenience of the rele-

vant Beneficiary or service provider;

d. Outcome studies are available and acceptable to the

Society; and

e. No alternative exists that has a better outcome, is more cost

effective and has a lower risk.

in this regard, the presence or absence of a medical necessity shall

be determined by the Society taking into account the above require-

ments. The fact that a provider has prescribed, recommended,

approved or provided a treatment, service, supply or confinement

shall not in itself be regarded as proof that such service was medi-

cally necessary. The Society may refer cases to a medical specialist

for an opinion, or a second opinion. The decision of the Society on

the issue of medical necessity following the advice of such special-

ist shall be final.

34. expenses for which a third party is liable including expenses asso-

ciated with occupational injuries and diseases, motor vehicle

accidents and medical services covered by other forms of insur-

ance, provided that the Society may provide benefits until the third

party’s liability has been established at which stage the expenditure

shall be recouped from the third party or the Beneficiary as the case

may be.

To what extent are benefits limited by the Society?1. The maximum benefits to which a member and his dependants are

entitled during any financial year of the Society are limited to the

extent set out in Annexure B to the rules.


Where will I be covered?Cover for benefits as outlined in the benefit table starting on page 31 only applies within the republic of South Africa (Area of Operation), except for the following instances where coverage will be provided in Botswana and Namibia:

• Benefits will be extended to members and their dependants in

Botswana or Namibia during the employment of such members

by the employer or an associated employer in either of those

countries; and

• Members or dependants who are enjoying benefits in respect of

relevant health services rendered in Botswana or Namibia will, on

becoming pensioner members, continue to enjoy such benefits for

as long as they remain permanent residents of the country in which

they were receiving benefits at the time when they became retirees

as provided for in rule 6.2, or became eligible for membership as

provided for in rule 6.3 (as the case may be).

Members should note that no benefit will be provided to members who reside in South Africa if they travel outside the country, even to Namibia and Botswana. if you travel to foreign countries for work, your employer will be responsible to provide you with insurance and if you travel on holiday outside South Africa you should obtain your own private medical travel insurance.

• Where will i be covered?

• Who manages the Society?

09 More about the Society>>

Ab

out the

So

ciety

More about the Society


Who manages the Society?The Society is managed by a Board of Trustees and the Trustees elect the Chairman of the Board from within their ranks. The Board is made up of eight members, of which four are employer-appointed Trustees and four are member-elected Trustees.

employer–appointed Trustees:

• Colin Blanckenberg (Chairman)

• Craig Coltman

• roger Ketley

• Wayne Smerdon

Member-elected Trustees:

• Pat Bartlett

• Bernard Bishop

• Huck endersby

• Hans Gastrow

All about membership


Who qualifies to be a member?

Employees

employees are required to join the Society, provided that a member who ceases to be an employee during a calendar month shall be entitled to retain his membership up to the last day of such calendar month.

Retirees

A member shall retain his membership of the Society when he retires from the service of the employer or an associated employer, or when his employment is terminated by his employer or associated employer on account of his retirement or becoming entitled to the insured dis-ability benefit offered by the employer.

The Society shall in writing inform the member of the continuation of his membership in terms of the rules and of the contribution payable from the date of his retirement or termination of his employment. unless such member informs the Society in writing of the termination of his membership, he shall continue to be a member.

Dependants of deceased members

The dependants of a deceased member who are registered with the Society as his dependants at the time of such member’s death shall be entitled to continuation membership of the Society.

• Who qualifies to be a member?

• What waiting periods apply to new members?

• What if a beneficiary has not been a member of a medical aid before?

• Can i or any of my dependants belong to more than one medical scheme at the same time?

10 All about membership>>

Mem

bership of S

ociety



The Society shall in writing inform the dependant of his right to mem-bership with effect from the date of death of the member referred to in the rules and of the contributions payable in respect thereof. unless such dependant informs the Society in writing of his intention to not become a member, he shall be admitted as a member of the Society.

Such dependant’s membership terminates if he becomes a member or a dependant of a member of another medical scheme.

Retrenched employees

A member who is retrenched from the service of the employer or associated employer may continue membership of the Society, provided that;

• the member does not become entitled to membership of

another medical scheme by virtue of any post-retrenchment

employment; and

• the Society may terminate the membership of such member if

he secures permanent employment with any employer, other

than the principal employer or associated employer, entitling him

to membership of another medical scheme by virtue of such

permanent employment.

Dependant

• a member’s spouse or partner who is not a member of another

medical scheme or a registered dependant of a member of another

medical scheme;

• a member’s child who is dependent on the member and is not a

member of another medical scheme or a registered dependant of a

member of another medical scheme;

• a member of the member’s immediate family for whom the member

is liable for family care and support; or

• any sibling of a child dependant, if such child dependant has been

orphaned or if such child dependant’s remaining parent does not

qualify for registration as a member and, as a consequence thereof,

such child dependant is registered as a member in terms of rule

6.3.1, provided that such sibling was registered as a dependant of

the deceased member at the time of the death of the member and

provided that such sibling;

- is under the age of 21; or

- is over the age of 21 but dependent (refer to ruling 9 on the

Society’s website for the criteria for dependency test).

Child

• a member’s natural child, stepchild or legally adopted child; and

• a deceased member’s natural child, stepchild or legally adopted

child who, on the death of the member, is entitled to be registered

as a member in terms of rule 6.3.1 under circumstances where such

child is orphaned or such child’s remaining parent does not qualify

for continuation membership.



Child dependant

• a dependent child, who is under the age of 26.

Dependent child

• a child under the age of 21; or

• a child over the age of 21 but who is dependent upon the member.

What waiting periods apply to new members?This is a general three-month period after joining the Society during which a beneficiary is not entitled to claim any benefits. A waiting period may be imposed by the Society in specific circumstances and no claims will be paid in respect of the registered beneficiary during this period. in cases where a condition-specific waiting period of twelve months has been imposed, the beneficiary is not entitled to claim any benefits related to the specific condition in question for a period of 12 months.

The Society may impose upon a person in respect of whom an appli-cation is made for membership or registration as a dependant and who was not a beneficiary of a medical scheme during the period of 90 days preceding the date of application –

• a general waiting period of up to three months; and

• a condition-specific waiting period of up to 12 months.

These waiting periods shall also apply in respect of any treatment or diagnostic procedures covered by the PMBs.

The Society may impose upon any person in respect of whom an application is made for membership or registration as a dependant and who was previously a beneficiary of a medical scheme for a con-tinuous period of more than 24 months, terminating less than 90 days immediately prior to the date of application, a general waiting period of up to three months, except in respect of any treatment or diagnos-tic procedures covered within the PMBs.

No waiting periods shall be imposed on a person in respect of whom an application is made for membership or registration as a depend-ant, who was previously a beneficiary of a medical scheme and whose membership with such medical scheme terminated less than 90 days immediately prior to the date of application, where the change of membership is required as a result of:

• a change of employment;

• an employer changing or terminating the medical scheme of its

employees and a transfer of membership occurs at the beginning of

the Society’s financial year, provided that reasonable written notice

of such change of membership was given to the Society; or

• a child born during the period of membership.

Where the former medical scheme has imposed a general or condition specific waiting period in respect of a person referred to in the applica-ble rules of the Society, and such waiting period has not expired at the time of the termination of such person’s membership of that medical

Mem

bership of S

ociety



scheme, the Society may impose a waiting period for the unexpired duration of the waiting period imposed by the former scheme.

What if a beneficiary has not been a member of a medical aid before?Late joiner penalties may be imposed on beneficiaries over the age of 35 depending on the number of years that they have not belonged to a medical aid.

A late joiner penalty will be added to the member’s monthly contribu-tion in respect of the beneficiary. it is based on the total number of years the beneficiary has not been a medical aid member since the age of 35 years and is calculated as a percentage of the contribution as shown in the table below.

Penalty Bands Maximum penalty

1 – 4 years 0.05 x contribution



25 + years 0.75 x contribution

Can I or any of my dependants belong to more than one medical scheme at the same time?

Please note that it is illegal to belong to more than one medical scheme at the same time.

Claiming and co-payments


How much time do I have to claim a benefit?Please submit your claims as soon as possible, but no later than four months from the date on which the service was rendered. in terms of the Medical Schemes Act, claims not submitted within four months may not be considered for payment by the Society.

How can I ensure that my GP and other health-care service providers are paid timeously?in the interest of efficiency and reducing the risk of fraud, the Society’s policy is to pay all service providers only via electronic funds transfer (eFT) and claims are processed and paid within a maximum period of 21 calendar days of receipt. in view of this, members are encour-aged to advise their service providers accordingly and to ensure that the Society is provided with their banking details to ensure that they receive their payments timeously.

Can I settle my co-payments by paying service providers directly?if you do not want the Society to pay the service provider’s claimed amount on your behalf and collect co-payments from your salary or pension, please notify the Society in writing. in such cases the Society will only settle its liability with the service provider according to the rules, and the member will be required to settle the remaining portion of the account directly with the service provider.

• How much time do i have to claim a benefit?

• How can i ensure that my GP and other health-care service providers are paid timeously?

• Can i settle my co-payments by paying service providers directly?

• How can i avoid co-payments for after-hours/unscheduled doctors’ consultations?

11 Claiming and co-payments>>

Claim

ing

Claiming and co-payments


in cases where members settle service provider accounts directly, claims may be submitted to the Society, via e-mail ([email protected]) or fax (0866 368 923). Such claims should include the original invoice, which indicates the member and benefi-ciary’s detail, iCD 10 code, the tariff and the amount per tariff claimed, together with a receipt confirming payment. The member should sign the claim to certify its correctness and indicate that it should be refunded to the member. Such claims will be processed and refunded in terms of the Society’s rules and benefits via payroll.

Please note these claims must be submitted to the Society within four (4) months from the date that the service was ren-dered failing which they will not be honoured.

How can I avoid co-payments for after-hours/unscheduled doctors’ consultations?Please note that any after-hours and any unscheduled doctor’s con-sultations (which are not emergencies) will only qualify for a benefit at the normal doctor’s consultation SrPL rates. Any additional consul-tation charges will not be settled by the Society and the member will need to pay the provider directly. For example, if you visit the doctor after hours for a non-emergency consultation, the Society will pay the normal consultation rate to the provider and the member will be liable to pay any other consultation fees charged by the service pro-vider. remember to check with the receptionist when an “after-hours or unscheduled visit” fee will be charged.

Most doctors (including facilities such as Medi-Cross) charge an after-hours consultation fee for consultations conducted after normal working hours and during week-ends. Also note that, if you phone your doctor during normal working hours and he/she fits you in on that specific day without an official pre-booked appointment, you will be charged for an unscheduled consultation. You will be liable for the standard 10% co-payment of the normal consultation fee plus any additional amount charged by the doctor.

Doctor’s house calls will be paid at normal consultation rates unless clinically assessed to be medical emergencies.

Members who are of the opinion that their after-hours/unscheduled consultation took place as a result of a medical emergency, as defined previously, can submit a written request providing detail of the emer-gency for review and consideration by the Society. These submissions can be sent to [email protected] or faxed to 0866 368 923.

Frequently asked questions


How are benefits calculated?Benefits are calculated according to the De Beers Benefit Society reference Price List (SrPL). The National Health reference Price List (NHrPL) was an industry agreed price list for medical services pub-lished by the National Department of Health up to 2006 at which point it was found to be anti-competitive and outlawed. Aligned to medical aid industry practice, the Society adopted its own reference price list, the SrPL, which is based on the NHrPL as it existed until 2006, but adjusted annually to take account of inflation and other changes. The SrPL documents all registered services (Doctors billing guide) pro-vided by medical service providers and the rates for such services recognised as the basis for reimbursement of claims by the Society.

How will my service providers be paid?in cases where service providers charge the SrPL rate, the Society will pay the service provider directly and in full (if there are any co-pay-ments due, these will be collected via the member’s salary/pension subject to credit limits).

Where service providers charge in excess of the SrPL, the Society will automatically refund the member the Society’s liability and the member will have to settle the account directly with the service provider. The reason for doing this is to protect members from auto-matically being debited with co-payments and paying the service provider in full where the service provider charges excessively.

• How are benefits calculated?

• How will my service providers be paid?

• What happens to “unused” benefit limits from the risk pool?

• What do i do if i suspect that someone is defrauding the Society?

• What if i have a complaint against the Society?

• What if i have a complaint related to other aspects of the health industry?

12 Frequently asked questions>>

FAQ

s



Members can instruct the Society to always only pay the SrPL and not to pay the provider in full under any circumstance. if a member elects to make use of this system then the member will always have to pay all co-payments at point-of-sale at all times.

What happens to “unused” benefit limits from the risk pool?The Society is a traditional medical scheme where all members’ con-tributions are pooled together in a single risk pool from which benefits are paid. On an annual basis the Trustees (together with assistance from industry experts) set the budget for the ensuing year. This is a complex process and the Trustees take account of a number of factors including, for example:

• past claims experience;

• projected future increases in the cost of services;

• the demographics of the Society’s membership;

• developments in the medical industry;

• investment returns; and affordability.

Based on the outcome of the above, the Trustees aim to set the con-tributions at a level that will cover the cost of the benefits provided. if a situation occurs where too much or too little is collected from members, this has an influence on the solvency of the Society and the outcome will either increase the reserves of the Society, or decrease

these. The aim is to ensure that the Society remains solvent and sus-tainable over the long term so any “unused” benefits will increase the funds that the Society has available in future years to provide benefits to all of its members.

What do I do if I suspect that someone is defrauding the Society?Phone the Society’s toll-free Fraud Line on 0800 204 724 or use the anonymous email facility on www.dbbs.co.za (under Fraud).

Allcallsandemailswillbetreatedconfidentiallyandyouwillnothavetodiscloseanypersonaldetails.Pleasegiveasmuchdetailaboutthesuspectedinstanceoffraudaspossi-bletoassistintheinvestigation.

What if I have a complaint against the Society?Members may lodge complaints in writing to the Society via e-mail ([email protected]) or post (PO Box 1922, Kimberley, 8300) for the attention of the Principal Officer.

All complaints received in writing will be responded to by the Society, in writing, within 30 days of receipt thereof.

Any dispute may be referred to an expert committee for an opinion. A final decision by the Principal Officer in consultation with the Chairman of the Board regarding the dispute will be binding on both parties in terms of the rules of the Society.



Any member has the right to submit a complaint to the Council for Medical Schemes against the decision of the Principal Officer. Such complaint must be submitted to the Council and needs to be furnished to the registrar not later than three months after the date on which the decision in question was made by the Principal

Officer. For a detailed process to follow to submit a complaint to the Council for Medical Schemes, please make use of their website (www.medicalschemes.com) or contact them as per the contact details below.

CustomerCareServiceCenter/Reception0861 123 267 Telephone: (012) 431 05000861 123 cms Fax: (012) 430 7644

GeneralEnquiries/Complaintsemail enquiries: [email protected] Fax Complaints: (012) 431-0608 email Complaints: [email protected]

PostalAddress PhysicalAddressPrivate Bag X34 Block AHatfield eco Glades 2 Office Park0028 420 Witch-Hazel Avenue eco Park Centurion 0157Website: http://www.medicalschemes.com

FAQ

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Laying a complaint with the Council for Medical Schemes (CMS) about the SocietyAny beneficiary or any person who is aggrieved with the conduct of a medical scheme can submit a complaint to the CMS. it is however very important to note that a prospective complainant should always first seek to resolve complaints through the complaints mechanisms in place at the respective medical scheme (as noted above in the case of the Society) before approaching the CMS for assistance. Com-plaints can be submitted by any reasonable means such as a letter, fax, e-mail or in person at the CMS office from Mondays to Fridays during 08:00 – 17:00.

Please access the Council’s website for the complaint form.

The CMS governs the medical schemes industry and therefore your complaint should be related to your medical scheme.

Council for Medical Schemes time limits for dealing with complaintsThe CMS aims to provide a transparent, equitable, accessible, expedi-tious as well as a reasonable and procedurally fair dispute resolution process. The registrar of the CMS will send a written acknowledge-ment of a complaint within three working days of its receipt, providing the name, reference number and contact details of the person who will be dealing with a complaint.

in terms of Section 47 of the Medical Schemes Act 131 of 1998, a written complaint received in relation to any matter provided for in that Act will be referred to the medical scheme. The medical scheme is obliged to provide a written response to the registrar’s Office within 30 days. The registrar’s Office shall analyse the complaint within four days of receiving the complaint from the administrator, and refer a complaint to a medical scheme for comments.

upon receipt of the response from the medical scheme, the regis-trar’s Office will analyse the response in order to make a decision or ruling. Decisions/rulings will be made within 120 days of the date of referral of a complaint and communicated to the parties.

Management of the Society would urge all members to ensure that they have exhausted all avenues, as set out above, before taking up the CMS’s valuable time that if dealt with correctly could be resolved at Society level. Members may lodge complaints, in writing to the Society via e-mail ([email protected]) or post (PO Box 1922, Kimberley, 8300) for the attention of the Principal Officer.



The Registrar’s Ruling and appeal to CouncilSection 49 of the Act makes provision for any party who is aggrieved with the decision of the registrar to appeal such a decision. This appeal is at no cost to either of the parties. An appeal must be lodged within 30 days of the date of the decision. The implementation of the decision shall be suspended pending review of the matter by the Council’s Appeal Committee. The secretariat of the Appeals Commit-tee will inform all parties involved of the date and time of the hearing. This notice should be provided no less than 14 days before the date of the hearing. The parties may appear before the Committee and tender evidence or submit written arguments or explanations in person or through a representative. The Appeals Committee may after the hearing confirm or vary the decision concerned or rescind it and give another decision as they see just.

The Section 50 Appeals processAny party that is aggrieved with the decision of the Appeals Commit-tee may appeal to the Appeal Board.

The aggrieved party has 60 days within which to appeal the decision and must submit written arguments or explanations of the grounds of his or her appeal. The Appeal Board shall determine the date, time and venue for the hearing and all parties will be notified in writing. Appeal Board shall be heard in public unless the chairperson decides otherwise. The Appeal Board shall have the powers which the High

Court has to summon witnesses, to cause an oath or affirmation to be administered by them, to examine them, and to call for the produc-tion of books, documents and objects. The decisions of the Appeal Board are in writing and a copy thereof shall be furnished to parties.

A prescribed fee of r2 000 is payable for Section 50 Appeals.

What if I have a complaint related to other aspects of the health industry?if you have a complaint related to any other aspect of the health indus-try, please follow the links below:

• For complaints against Health Professionals (doctors)

– www.hpcsa.co.za

• For complaints against Private Hospitals – www.hasa.co.za

• For complaints against Nurses – www.sanc.co.za

• For complaints against Brokers – www.faisombud.co.za

• For complaints in respect of other health insurance products

– www.osti.co.za (short term insurance ombudsman) or

www.ombud.co.za (long term insurance ombudsman

FAQ

s

List of Network Hospitals


List of Network HospitalsTOWN HOSPITAL NAME TEL. NUMBER STREET ADDRESS

Western Cape

Athlone Gatesville Medical Centre (021) 637-8100 Clinic Road, Gatesville

Bellville Cape Eye Hospital (021) 948-8884 Cnr Oosterzee street & DJ Wood Way

Bellville Louis Leipoldt Medi-Clinic (021) 957-6000 7 Broadway street

Brackenfell Cape Gate Medi-Clinic (021) 983-5600 Cnr Okavango road & Tanner

Cape Town Cape Town Medi-Clinic (021) 464-5500 21 Hof Street, Oranjezicht

Cape Town UCT Private Academic Hospital (021) 442-1800 D 18 New Main Building, Anzio Road, Observatory

Ceres Ceres Private Hospital (023) 316-1304 2 Faure Street

Durbanville Durbanville Medi-Clinic (021) 980-2100 45 Wellington Road

George Geneva Medi-Clinic (044 803-2000 7 Varing Avenue, Dornehlsdrift

George George Medi-Clinic (044) 803-2000 Cnr York Street & Gloucester Avenue

Hermanus Hermanus Medi-Clinic (028) 313-0168 Hospital Street

Knysna Knysna Private Hospital (044) 384-1083 Hunters estate

Milnerton Milnerton Medi-Clinic (021) 529-9000 Cnr Racecourse & Koeberg Roads

Mitchells Plain Mitchells Plain Medical Centre (021) 392-3126 Symphony Walk, Town Centre



TOWN HOSPITAL NAME TEL. NUMBER STREET ADDRESS

Mossel Bay Bayview Hospital (044) 691-3718 Cnr Alhof Drive & Ryk Tulbagh Street

Oudtshoorn Klein Karoo Medi-Clinic (044) 272-0111 185 Church Street

Paarl Paarl Medi-Clinic (021) 807-8000 Berlyn Street, Northern Paarl

Parow Panorama Medi-Clinic (021) 938-2111 Rothschild Boulevard, Panorama

Plettenberg Bay Plettenberg Bay Medi-Clinic (044) 501-5100 Muller Street, Plettenberg Bay

Plumstead Constantiaberg Medi-Clinic (021) 799-2911 Burnham Road

Somerset West Vergelegen Medi-Clinic (021) 850-9000 Main Road, Somerset West

Stellenbosch Stellenbosch Medi-Clinic (021) 861-2000 Cnr Saffraan & Rokewood Avenue

Strand Medi-Clinic Strand (021) 854-7663 Altena street

Vredenburg West Coast Private Hospital (022) 719-1030 22 Voortrekker Road

Worcester Worcester Medi-Clinic (023) 348-1500 67 Fairbairn Street

Northern Cape

Kathu Kathu Medi-Clinic (053) 723-3231 Frikkie Meyer Road

Kimberley Kimberley Medi-Clinic (053) 838-1111 177 Du Toitspan Road

Upington Upington Medi-Clinic (054) 338-8900 Cnr 4th Avenue & Du Toit Street

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Gauteng

Alberton Clinton Clinic (011) 724-2300 62 Clinton Road, New Redruth

Alberton Mulbarton Hospital (011) 432-3930 25 True North Road

Alberton Union Hospital (011) 724-2000 47 Clinton Road, New Redruth

Bedfordview Bedford Gardens Private Hospital (011) 677-8500 7 Leicester Road

Benoni The Glynnwood (011) 741-5000 33-35 Harrison Street

Benoni Sunshine Hospital (011) 420-3000 1522 Soma Street, Actonville

Benoni Optiklin Eye Hospital (011 918-5478 104 Klein Street, Lakefield Ext

Boksburg Sunward Park Hospital (011) 897-1600 Cnr Kingfisher Avenue, Aquarius & Bert Lacey Drive

Brakpan Dalview Clinic (011) 747-0747 11 Hendrik Potgieter Road

Bryanston Sandton Medi-Clinic (011) 709-2000 Cnr Peter Place & Main Road

Cramer View Medfem Clinic (011) 463-2244 Cnr Peter Place & Nursery Road, Bryanston

Halfway House Carstenhof Clinic (011) 655-5500 21 Dane Road, Glen Austin, Midrand

Heidelberg Suikerbosrand Clinic (016) 342-9200 Cnr H F Verwoerd & Maré Streets




Honeydew Wilgeheuwel Hospital (011) 796-6500 Amplifier street, Radio Kop Ext 13, Roodepoort

Johannesburg Brenthurst Clinic (011) 647-9000 4 Parklane Road, Parktown

Johannesburg Wits University Donald Gordon Medical Centre

(011) 356-6000 21 Eton Road, Parktown

Johannesburg Garden City Hospital (011) 495-5000 35 Bartlett Road, Mayfair West

Kempton Park Arwyp Medical Centre (011 922-1000 20 Pine Avenue, Kempton Park

Krugersdorp Bellstreet Hospital (011) 954-1023 Cnr Bell & Shannon Road, Noordheuwel

Krugersdorp Krugersdorp Hospital (011) 951-0200 9 Burger Street

Lenasia Lenmed Clinic (011) 213-2000 K43 Highway Ext 8

Morningside Morningside Medi-Clinic (011) 282-5000 Cnr Rivonia & Hill Roads

Primrose Roseacres Clinic (011) 842-7500 Cnr Castor &St Joseph Streets Germiston

Randfontein Robinson Hospital (011) 278-8700 1 Hospital Road

Soweto Tsepo Themba Clinic (011) 983-0300 Cnr Bram Fischer & Elias Motswaledi Road, Dobsonville

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Springs Springs Parkland Hospital (011) 812-4000 Spring 86 Artemis Road, Pollak Park

Springs St Mary’s Women’s Clinic (011) 815-6885 15 Middlesex Road Springs Ext

Vanderbijlpark Emfuleni Medi-Clinic (016) 950-8000 6 Jan van Riebeeck Boulevard

Vereeniging Vereeniging Medi-Clinic (016) 440-5000 Cnr Hofmeyer Avenue & Joubert Street

Weltevreden Park Flora Clinic (011) 470-7777 William Nicol Street-North, Flora Cliff

Pretoria

Mabopane Legae Medi-Clinic (012) 797-8000 8560 Unit M Old Mabopane

Pretoria Medforum Medi-Clinic (012) 317-6700 412 Schoeman Street

Pretoria Muelmed Medi-Clinic (012) 440-0600 577 Pretorius Street, Arcadia

Pretoria Medi-Clinic Gynecological Hospital (012) 400-8700 132 Cilliers Street

Pretoria Medi-Clinic Heart Hospital (012) 440-0200 551 Park Street, Arcadia

Pretoria Kloof Medi Clinic (012) 367-4000 511 Jochemus Street, Erasmuskloof Ext 3

Pretoria Pretoria Urology Hospital (012) 423-4000 Cnr Grosvenor & Pretorius Street, Hatfield

Pretoria Pretoria Eye Institute (012) 343-5873 630 Francis Baard Street, Arcadia




Pretoria Little Company of Mary Hospital – For Radiotherapy only

(012) 424-3600 50 George Storrar Drive, Groenkloof

Free State

Bethlehem Hoogland Medi-Clinic (058) 307-2000 4 De Leeuw Street

Bloemfontein Bloemfontein Medi-Clinic (051) 404-6666 Cnr Kellner Street & Parfitt Street, Westdene

Bloemfontein Bloemfontein Eye Centre – For Ophthalmology only

(051) 502-1900 54 Pasteur Avenue Hospital Park

Bloemfontein Rosepark – For Radiotherapy only (051) 505-5111 57 Gustav Avenue, Fichardtpark

Frankfort Riemland Kliniek (058) 813-2771 Cnr Collin & Frankfort Street

Kroonstad Kroon Hospital (056) 215-1881 North Way

Welkom Welkom Medi-Clinic (057) 916-5555 Meulen Street

eastern Cape

East London East London Private Hospital (043) 722-3128 32 Albany Street

East London St Dominic’s Hospital (043) 707-9000 45 St. Marks Road, Southernwood

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East London St James’ Hospital (043) 722-9685 36 St James Road, Southernwood

Humansdorp Isivivana Private Hospital (042) 200-4250 Du Plessis Street

Port Alfred Port Alfred Hospital (046) 604-4000 Southwell Road

Port Elizabeth Mercantile Hospital (041) 401-2700 Cnr Kempston & Durban Roads, Korsten

Port Elizabeth St Georges Hospital (041) 392-6111 40 Park Drive, Central

Queenstown Queenstown Private Hospital (045) 838-4110 Cnr, Griffith & Ebden Streets

Uitenhage Cuyler Clinic (041) 995-9000 34 Cuyler Street

Umtata St Mary’s Private Hospital (047) 505-5600 30 Durhan Road

North West

Brits Brits Medi-Clinic (012) 252-8000 8 Church/Kerk Street

Fochville Fochville Hospital (018) 771-2021 3rd Street 10

Klerksdorp Life Anncron Clinic (018) 468-1031 Cnr Dr.Yusuf Dadoo & Hartley Streets, Wilkoppies

Mafikeng Victoria Hospital (018) 397-7300 Victoria Road

Potchefstroom Potchefstroom Medi-Clinic (018) 293-7000 66 Meyer Street




Rustenburg Peglerae Hospital (014) 597-7200 173 Beyers Naude Drive

Vryburg Vryburg Private Hospital (053) 928-3000 67 Molopo Street

Limpopo

Lephalala Marapong Private Hospital (014) 768-2380 175 Mosethla Street

Louis Trichardt Zoutpansberg Private Hospital (015) 516-0720 47 Joubert Street

Polokwane Limpopo Medi-Clinic (015) 290-3600 53 Plein Street

Thabazimbi Thabazimbi Medi-Clinic (014) 777-2097 1 Hospital street

Tzaneen Tzaneen Medi-Clinic (015) 306-8500 Wolkberg Drive, R71

Warmbaths St Vincent’s Hospital (014) 736-2310 Cnr. Kwagga & Meiminger Streets, Bela Bela

Mpumalanga

Barberton Barberton Medi-Clinic (013) 712-4279 Cnr Sheba & Havelock Streets

Bronkhorstspruit Bronkhorstspruit Hospital (013) 932-9700 1 Barney Hurwitz Street

Ermelo Ermelo Medi-Clinic (017) 801-2600 25 Melmentz Street

Middelburg Middelburg Private Hospital (013) 283-8700 Cnr Mark & Joubert Street

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Nelspruit Nelspruit Medi-Clinic (013) 759-0500 1 Louise Street, Sonheuwel

Secunda Secunda Medi-Clinic (017) 631-1772 Heunis Street, Secunda

Secunda Highveld Medi-Clinic (017) 638-8000 Barney Molokwane Street in Trichardt

Witbank Cosmos Hospital (013) 653 8000 Cnr O.R.Tambo & Beaty Street

Kwa-Zulu Natal

Amanzimtoti Kingsway Hospital (031) 904-7000 607 Kingsway Road

Ballito Bay Alberlito Hospital (032) 946-6700 Kirsty Close, Ballito

Durban Entabeni Hospital (031) 204-1300 148 South Ridge Road, Berea

Empangeni Empangeni Garden Clinic (035) 902-8000 Cnr Ukulu and Biyela Streets

Howick Howick Private Hospital (033) 330 - 2456 107 Main Street

Margate Margate Hospital (039) 312-7300 24 Wartski Drive

Newcastle Newcastle Private Hospital (034) 317 -0000 Cnr Hospital & Birch Streets

Phoenix Mount Edgecombe Hospital (031) 537-4000 163 / 5 Redberry Road, Rockford

Pietermaritzburg Pietermaritzburg Medi-Clinic (033) 845-3700 90 Payne Street

Pongola Pongola Hospital (034) 413-1372 82 Hansdons Street




Port Shepstone Hibiscus Hospital (039) 682-4882 George Street

Richards Bay The Bay Hospital (035) 780-6111 6 Krugerrand Road CBD

Tongaat Victoria Hospital (032) 944-5061 35 High Street

Umhlanga Umhlanga Hospital (031) 560-5500 323 Umhlanga Rocks Drive

Underberg Riverview Country Hospital (033) 701-1911 1 Umzimkulu, Road & Cnr.Main road

Westville Westville Hospital (031) 265-0911 7 Spine Road

Namibia

Windhoek Windhoek Medical Centre +26 46 122 2687 Heliodoor Street

Otjiwarongo (Namibia) Otjiwarongo Hospital +26 465 130 3734 Sonn Street, Otjiwarongo

Swakopmund Medi-Clinic Cottage +26 46 441 2200 Franziska van Neel Street

Botswana

Gaborone Gaborone Private Hospital +267 390 1999 Segoditshane Road

Gaborone Bokamoso Private Hospital +267 369 4000 Mmopane village

Orapa Orapa Mine Hospital Orapa Mine

Jwaneng Jwaneng Mine Hospital Jwaneng Mine

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A registered medical scheme. registration no. 1068

de beers benefit society guide/2014... · de beers benefit society member guide | 3 contents...

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