*This brochure is a summary of the benefits of Compcare Wellness Medical Scheme. A copy of the current Rules may be obtained from the Administrator,if so required. The Rules of the Scheme will always take precedence over this summary.

For nearly 30 years CompCare has been providing quality medical services to the industry and continues by offering a unique NetworX option specifically designed for young individuals. The NetworX option offers essential cover within a contracted provider network for in- and out-of-hospital services.

COMPREHENSIVE MEDICAL COVER

FOR STUDENTS FROM ONLY

R306 PER MONTH

TheNetworX Option

MAJOR MEDICAL EXPENSES

Network of private hospitals

Unlimited prescribed minimum benefits (PMB)

Annual Hospital Limit:

R250 000 per beneficiary (p/b) &

R500 000 per family (p/f) (non-PMB and elective admissions)

Blood pressure, blood sugar, cholesterol, Body Mass Index (BMI) and waist circumference

Flu vaccinations

WELLNESS AND PREVENTATIVE CARE

GP consultations – unlimited, subject to clinical necessity, within the Universal Healthcare Provider Network

Acute and chronic medication

Radiology

Pathology

Basic dentistry

Optometry

Specialist consultations

Hospital emergency room/casualty emergency visits

OUT-OF-HOSPITAL BENEFITS

Gross monthly income

Principalmember

Adultdependant

Childdependant

R0 - R500 R 306.00 R 306.00 R 168.00

MONTHLY CONTRIBUTION*

In-hospital benefitsPrescribed Minimum Benefits:

Overall Annual Limit (OAL): for non-PMB and elective admissions

• Unlimited – subject to scheme protocols

• R250 000 per beneficiary & R500 000 per family

Services Covered in Hospital

100% of the Agreed Tariff (AT), subject to the OAL, pre-authorisation and network of private hospitals. All treatment in hospital is subject to case management and scheme protocols

• GPs and specialists

• Ward fees – general; ICU and High Care

• Theatre fees

• Medication whilst in hospital

• Blood transfusion

• Oncology – chemotherapy and radiotherapy

• Surgical prosthesis (PMB only)

• Clinical technologists limited to R8 000 p/f

• Radiology – MR, CT and PET scans

• Confinements limited 3 days for normal birth days and 4 days for Caesarean section

• Psychiatric treatment is limited to 21 days in hospital

• Organ and bone marrow transplants, plasmapheresis and renal dialysis (PMB only)

• Sports injuries, including professional sports

• Emergency medical treatment for injuries resulting from accidents or trauma

Cover for Chronic Conditions

27 Chronic conditions covered

Chronic medication is subject to the Core Formulary list of medicines and a Formulary Reference Price (FRP). Members are required to register for all chronic conditions

• Chronic medication is unlimited, subject to medicine formulary and if prescribed by network provider and dispensed within network pharmacy or dispensing network doctor. Any voluntary use of chronic medicine prescribed by out-of-network provider and any non-formulary medicines are for the member’s own account, unless pre-authorised by the medical advisor. PMB rules apply

• Subject to FRP

Day-to-day services not subject to the Annual Flexi Benefit (AFB)

• GP visits - unlimited at a selected Universal Healthcare network GP, subject to clinical necessity

• Two out of area visits p/b per annum (pay at point of service and claim back). Claims reimbursed at 80% of the cost of the claim to a maximum of R750 per event (i.e. for the GP consultation and all related costs)

• Acute medication - unlimited if prescribed by a network GP and subject to medicine formulary and FRP. Available at network pharmacies or dispensing network GP

• Basic radiology - unlimited, subject to specific codes - referral by the network GP required

• Basic pathology - unlimited, subject to specific codes - referral by the network GP required

Day-to-day services paid from the Annual Flexi Benefit (AFB) at 100% at the Agreed Tariff (AT)

AFB – R2000 p/b

R3000 p/f

• Specialist consultations - (limited to 2 p/b, max 3 p/f), subject to referral by Designated Service Provider (DSP) network GP

• Basic dentistry - (limited to 1 consultation p/b) including preventative care, infection control, fillings, extractions and dental x-rays

• Optometry - (limited to 1 test p/b every 24 months, including lenses – clear plastic - R600 for single vision and R750 for bi-focals, and frames)

• Hospital emergency room/casualty emergency visits

Wellness: Lifestyle and Preventative Care

• Blood pressure, blood sugar, cholesterol, BMI and waist circumference - limited to R100 p/b over the age of 18

• Flu vaccinations - 1 dose p/b per annum - limited to R70 paid from AFB

Tel: 011 208 1000Fax: 086 645 4727

E-mail: student@universal.co.zawebsite: www.universal.co.za/student.html

Administered by Universal Healthcare Administrators (Pty) Ltd

TheNetworX Option

APPLICATION FORM FOR STUDENTS

PERSONAL PARTICULARS

MEDICAL DETAILS

have ever experienced or YES NO

have received during the last twelve months or YES NO

anticipate receiving within the next twelve months YES NO

Please indicate and provide details of whether any medical treatment, including acute conditions, you or any of your dependants have ever experienced or have received during the last twelve months or anticipate receiving within the next twelve months.

If you answered “Yes” to any of the above questions, please provide details below:

Name Details of condition Date of treatment Degree of recovery

DEPENDANT DETAILS

Name Surname Relationship Gender Date of birth

yyyy/mm/dd

yyyy/mm/dd

yyyy/mm/dd

yyyy/mm/dd

Country of Origin Embassy

ID/Passport no

Study Institution Student no

Surname

First name/s

Title Marital status Nationality Present age

Date of birth

Postal address

Physical address

Email address

Telephone details

Facsimile details

(B) Code ( )

(B) Code ( )

(H) Code ( )

Cell:

Postal code

TheNetworX Option

Date of commencement End date

Confirmation to be sent via Fax E-mail SMS

d d m m y y y y

Please tick:

International Student National Student

DECLARATION

PAYMENT DETAILS

I authorise CompCare Wellness to debit the account below for all amounts due in respect of my membership of the Scheme.

Signature of applicant Signature of account holder

Members signature Date

Employer/University/Embassy Signature or Stamp Date

Brokerage name or broker name Broker code

Broker signature Date

Tel: +27 11 208 1000 • Fax: 086 645 4727 E-mail: student@universal.co.za • website: www.universal.co.za/student.html

Administered by Universal Healthcare Administrators (Pty) Ltd

Selected Doctor name(a list of contracted Doctors in your area can be found on www.universal.co.za)

Cash Credit transfer Credit card

Address of account holder

Passport no. of account holder

Account/credit card number

Name of bank

3 Digit credit card validation no

Monthly contribution

Branch code

Credit card expiry date

Months = Total deduction

Please select method of payment (please tick)

Name of account holder

Name of Doctor

R

1. I, the undersigned hereby apply for membership of CompCare Wellness Medical Scheme and agree that all answers and information contained in this application completed by me or by any other person/s will be the basis of the proposed agreement.2. I warrant that the contents of this application are true, correct and complete. No cover will be granted unless CompCare Wellness Medical Scheme specifically notifies me in writing of their acceptance of the risk, or on receipt of a valid membership card. Failure to comply with any of the terms and conditions of the agreement shall render the agreement null and void.3. I agree to abide by and undertake to familiarise myself with the rules of the scheme as amended from time and grant my employer the right to deduct from my remuneration any amounts (including members portion’s) outstanding by myself to CompCare Wellness Medical Scheme, including interest thereon. I further grant my employer the right to pay such monies over the scheme.4. I understand that the scheme will not be liable for reimbursement in respect of health services obtained for any pre-existing conditions, unless the details are fully disclosed, which may be subject to waiting periods and condition specific exclusions in accordance with the Medical Schemes Act (No. 131 of 1998).5. I agree to notify the scheme within 30 days in the event that any alternation in the circumstances on which the assessment of their risk is based, occurs between the date of this application and the date of their acceptance of the risk.6. The following will apply in respect of exchange of confidential information and medically confidential information concerning members and their dependants: 6.1. For the purpose of considering application/s for membership, as well as any claims for benefits, CompCare Wellness Medical Scheme and any medical personnel authorised by CompCare Wellness Medical Scheme has the right to obtain or forward any medically relevant information including the HIV/ AIDS status, which it may deem necessary from or to any medical practitioner or institution or nominee that possesses or needs such information, and that party may disclose such information to CompCare Wellness Medical Scheme and any party duly authorised by CompCare Wellness Medical Scheme. 6.2. The information may be requested and supplied at any time, including after the death of the member or dependants, and will include accounts from service providers, indicating diagnoses, and medical or clinical reports when indicated. Such information will, however, be treated as confidential at all times by the party to whom it is supplied. 6.3. By agreeing to sign the application form/s the applicant/member and dependants thereby waives his/her right to privacy in terms of the abovementioned clauses.7. I (the member) acknowledge that it is my sole responsibility as a member to ensure that the monthly premium is received by the scheme.8. Neither the applicant nor any of his/her dependant/s will/are be beneficiaries of another registered medical scheme, on the date of registration with CompCare Wellness Medical Scheme.9. I hereby indemnify and hold harmless the scheme and administrator against any and/or claims that may result due to the use of preferred providers.10. I hereby acknowledge that I must give 3 (three) months written notice when I voluntarily resign from the Medical Scheme.11. I hereby give the scheme permission to communicate to me by SMS Email

I declare that I have disclosed all particulars relevant to this application and that I am aware that any false statement or non-disclosure of information will relieve the scheme from liability and subject my membership cancellation. I warrant that I am authorised to sign on behalf of my dependant/s. If I am illiterate, I confirm that the content of this application form and the implications thereof have been read and explained to me.

Banking details:Account holder: CompCare Wellness Medical Scheme Bank: Nedbank Parktown Branch code: 194405 Acc number: 1944105972Swift no: NEDSZAJJ

Banking details:Account holder: CompCare Wellness Medical Scheme 1491Bank: Standard BankBranch code: Rivonia 1255 Acc number: 422070912Swift no: SBZAZAJJ

Banking details:Account holder: CompCare Wellness Medical Scheme Bank: ABSABranch code: 362005 Acc number: 4077182095Swift no: ABSAZAJJ

APPLICATION FORM FOR STUDENTS

PERSONAL PARTICULARS

MEDICAL DETAILS

have ever experienced or YES NO

have received during the last twelve months or YES NO

anticipate receiving within the next twelve months YES NO

Please indicate and provide details of whether any medical treatment, including acute conditions, you or any of your dependants have ever experienced or have received during the last twelve months or anticipate receiving within the next twelve months.

If you answered “Yes” to any of the above questions, please provide details below:

Name Details of condition Date of treatment Degree of recovery

DEPENDANT DETAILS

Name Surname Relationship Gender Date of birth

yyyy/mm/dd

yyyy/mm/dd

yyyy/mm/dd

yyyy/mm/dd

Country of Origin Embassy

ID/Passport no

Study Institution Student no

Surname

First name/s

Title Marital status Nationality Present age

Date of birth

Postal address

Physical address

Email address

Telephone details

Facsimile details

(B) Code ( )

(B) Code ( )

(H) Code ( )

Cell:

Postal code

TheNetworX OptionDate of commencement End date

Confirmation to be sent via Fax E-mail SMS

d d m m y y y y

DECLARATION

PAYMENT DETAILS

I authorise CompCare Wellness to debit the account below for all amounts due in respect of my membership of the Scheme.

Signature of applicant Signature of account holder

Members signature Date

Employer/University/Embassy Signature or Stamp Date

Brokerage name or broker name Broker code

Broker signature Date

Tel: +27 11 208 1000 • Fax: 086 645 4727 E-mail: student@universal.co.za • website: www.universal.co.za/student.html

Administered by Universal Healthcare Administrators (Pty) Ltd

Selected Doctor name(a list of contracted Doctors in your area can be found on www.universal.co.za)

Cash Credit transfer Credit card

Address of account holder

Passport no. of account holder

Account/credit card number

Name of bank

3 Digit credit card validation no

Monthly contribution

Branch code

Credit card expiry date

Months = Total deduction

Please select method of payment (please tick)

Name of account holder

Name of Doctor

R

1. I, the undersigned hereby apply for membership of CompCare Wellness Medical Scheme and agree that all answers and information contained in this application completed by me or by any other person/s will be the basis of the proposed agreement.2. I warrant that the contents of this application are true, correct and complete. No cover will be granted unless CompCare Wellness Medical Scheme specifically notifies me in writing of their acceptance of the risk, or on receipt of a valid membership card. Failure to comply with any of the terms and conditions of the agreement shall render the agreement null and void.3. I agree to abide by and undertake to familiarise myself with the rules of the scheme as amended from time and grant my employer the right to deduct from my remuneration any amounts (including members portion’s) outstanding by myself to CompCare Wellness Medical Scheme, including interest thereon. I further grant my employer the right to pay such monies over the scheme.4. I understand that the scheme will not be liable for reimbursement in respect of health services obtained for any pre-existing conditions, unless the details are fully disclosed, which may be subject to waiting periods and condition specific exclusions in accordance with the Medical Schemes Act (No. 131 of 1998).5. I agree to notify the scheme within 30 days in the event that any alternation in the circumstances on which the assessment of their risk is based, occurs between the date of this application and the date of their acceptance of the risk.6. The following will apply in respect of exchange of confidential information and medically confidential information concerning members and their dependants: 6.1. For the purpose of considering application/s for membership, as well as any claims for benefits, CompCare Wellness Medical Scheme and any medical personnel authorised by CompCare Wellness Medical Scheme has the right to obtain or forward any medically relevant information including the HIV/ AIDS status, which it may deem necessary from or to any medical practitioner or institution or nominee that possesses or needs such information, and that party may disclose such information to CompCare Wellness Medical Scheme and any party duly authorised by CompCare Wellness Medical Scheme. 6.2. The information may be requested and supplied at any time, including after the death of the member or dependants, and will include accounts from service providers, indicating diagnoses, and medical or clinical reports when indicated. Such information will, however, be treated as confidential at all times by the party to whom it is supplied. 6.3. By agreeing to sign the application form/s the applicant/member and dependants thereby waives his/her right to privacy in terms of the abovementioned clauses.7. I (the member) acknowledge that it is my sole responsibility as a member to ensure that the monthly premium is received by the scheme.8. Neither the applicant nor any of his/her dependant/s will/are be beneficiaries of another registered medical scheme, on the date of registration with CompCare Wellness Medical Scheme.9. I hereby indemnify and hold harmless the scheme and administrator against any and/or claims that may result due to the use of preferred providers.10. I hereby acknowledge that I must give 3 (three) months written notice when I voluntarily resign from the Medical Scheme.11. I hereby give the scheme permission to communicate to me by SMS Email

I declare that I have disclosed all particulars relevant to this application and that I am aware that any false statement or non-disclosure of information will relieve the scheme from liability and subject my membership cancellation. I warrant that I am authorised to sign on behalf of my dependant/s. If I am illiterate, I confirm that the content of this application form and the implications thereof have been read and explained to me.

Banking details:

Account holder: CompCare Wellness Medical Scheme

Bank: Nedbank Parktown

Branch code: 194405

Acc number: 1944105972

Swift no: NEDSZAJJ

Bank: Standard Bank

Branch code: Rivonia 1255

Acc number: 422070912

Swift no: SBZAZAJJ

Bank: ABSA

Branch code: 362005

Acc number: 4077182095

Swift no: ABSAZAJJ

APPLICATION FORM FOR STUDENTS

PERSONAL PARTICULARS

MEDICAL DETAILS

have ever experienced or YES NO

have received during the last twelve months or YES NO

anticipate receiving within the next twelve months YES NO

Please indicate and provide details of whether any medical treatment, including acute conditions, you or any of your dependants have ever experienced or have received during the last twelve months or anticipate receiving within the next twelve months.

If you answered “Yes” to any of the above questions, please provide details below:

Name Details of condition Date of treatment Degree of recovery

DEPENDANT DETAILS

Name Surname Relationship Gender Date of birth

yyyy/mm/dd

yyyy/mm/dd

yyyy/mm/dd

yyyy/mm/dd

Country of Origin Embassy

ID/Passport no

Study Institution Student no

Surname

First name/s

Title Marital status Nationality Present age

Date of birth

Postal address

Physical address

Email address

Telephone details

Facsimile details

(B) Code ( )

(B) Code ( )

(H) Code ( )

Cell:

Postal code

TheNetworX OptionDate of commencement End date

Confirmation to be sent via Fax E-mail SMS

d d m m y y y y

DECLARATION

PAYMENT DETAILS

I authorise CompCare Wellness to debit the account below for all amounts due in respect of my membership of the Scheme.

Signature of applicant Signature of account holder

Members signature Date

Employer/University/Embassy Signature or Stamp Date

Brokerage name or broker name Broker code

Broker signature Date

Tel: +27 11 208 1000 • Fax: 086 645 4727 E-mail: student@universal.co.za • website: www.universal.co.za/student.html

Administered by Universal Healthcare Administrators (Pty) Ltd

Selected Doctor name(a list of contracted Doctors in your area can be found on www.universal.co.za)

Cash Credit transfer Credit card

Address of account holder

Passport no. of account holder

Account/credit card number

Name of bank

3 Digit credit card validation no

Monthly contribution

Branch code

Credit card expiry date

Months = Total deduction

Please select method of payment (please tick)

Name of account holder

Name of Doctor

R

1. I, the undersigned hereby apply for membership of CompCare Wellness Medical Scheme and agree that all answers and information contained in this application completed by me or by any other person/s will be the basis of the proposed agreement.2. I warrant that the contents of this application are true, correct and complete. No cover will be granted unless CompCare Wellness Medical Scheme specifically notifies me in writing of their acceptance of the risk, or on receipt of a valid membership card. Failure to comply with any of the terms and conditions of the agreement shall render the agreement null and void.3. I agree to abide by and undertake to familiarise myself with the rules of the scheme as amended from time and grant my employer the right to deduct from my remuneration any amounts (including members portion’s) outstanding by myself to CompCare Wellness Medical Scheme, including interest thereon. I further grant my employer the right to pay such monies over the scheme.4. I understand that the scheme will not be liable for reimbursement in respect of health services obtained for any pre-existing conditions, unless the details are fully disclosed, which may be subject to waiting periods and condition specific exclusions in accordance with the Medical Schemes Act (No. 131 of 1998).5. I agree to notify the scheme within 30 days in the event that any alternation in the circumstances on which the assessment of their risk is based, occurs between the date of this application and the date of their acceptance of the risk.6. The following will apply in respect of exchange of confidential information and medically confidential information concerning members and their dependants: 6.1. For the purpose of considering application/s for membership, as well as any claims for benefits, CompCare Wellness Medical Scheme and any medical personnel authorised by CompCare Wellness Medical Scheme has the right to obtain or forward any medically relevant information including the HIV/ AIDS status, which it may deem necessary from or to any medical practitioner or institution or nominee that possesses or needs such information, and that party may disclose such information to CompCare Wellness Medical Scheme and any party duly authorised by CompCare Wellness Medical Scheme. 6.2. The information may be requested and supplied at any time, including after the death of the member or dependants, and will include accounts from service providers, indicating diagnoses, and medical or clinical reports when indicated. Such information will, however, be treated as confidential at all times by the party to whom it is supplied. 6.3. By agreeing to sign the application form/s the applicant/member and dependants thereby waives his/her right to privacy in terms of the abovementioned clauses.7. I (the member) acknowledge that it is my sole responsibility as a member to ensure that the monthly premium is received by the scheme.8. Neither the applicant nor any of his/her dependant/s will/are be beneficiaries of another registered medical scheme, on the date of registration with CompCare Wellness Medical Scheme.9. I hereby indemnify and hold harmless the scheme and administrator against any and/or claims that may result due to the use of preferred providers.10. I hereby acknowledge that I must give 3 (three) months written notice when I voluntarily resign from the Medical Scheme.11. I hereby give the scheme permission to communicate to me by SMS Email

I declare that I have disclosed all particulars relevant to this application and that I am aware that any false statement or non-disclosure of information will relieve the scheme from liability and subject my membership cancellation. I warrant that I am authorised to sign on behalf of my dependant/s. If I am illiterate, I confirm that the content of this application form and the implications thereof have been read and explained to me.

Banking details:Account holder: CompCare Wellness Medical Scheme

Bank: Nedbank Parktown

Branch code: 194405

Acc number: 1944105972

Swift no: NEDSZAJJ

Banking details:Account holder: CompCare Wellness Medical Scheme

1491

Bank: Standard Bank

Branch code: Rivonia 1255

Acc number: 422070912

Swift no: SBZAZAJJ

Banking details:Account holder: CompCare Wellness Medical Scheme

Bank: ABSA

Branch code: 362005

Acc number: 4077182095

Swift no: ABSAZAJJ

Medical cover fit for students2012

A healthcare solution designed to give students outstanding care at affordable rates. This plan offers R900 000 private

hospitalisation at any private hospital and offers a choice of preferred providers for your out-of-hospital healthcare needs.

How much will I pay? Member: R329 Adult Dependant: R329 Child Dependant: R180

Benefit Description Rate Benefit Notes

In-h

ospi

tal B

enef

its

Overall Annual Limit for all in-hospital benefits

100% of MHR R900 000 per family per year at any private hospital*

Pre-authorisation is required for all in-hospital treatment.

Contact us on 0860 102 493 48 hours prior to admission date

If authorisation is not obtained, a co-payment will apply to all claims relating to the treatment, provided authorisation would have been granted according to the Rules of the Scheme. In the case of an emergency, you, someone in your family or a friend, may obtain authorisation within 72 hours of admission

Internal prosthesis 100% of MHR No benefit Pre-authorisation required

Take-home medicine 100% of MHR Limited to 7 days supply per event Available on discharge from hospital

Maternity benefit 100% of MHR R19 500 per uncomplicated delivery and R29 000 per complicated delivery

A 12 month pregnancy exclusion will apply to female members who are pregnant when joining the Scheme

Pre-authorisation required

In-hospital dental and oral benefits

100% of MHR Not covered Maxillo-facial trauma covered at State facilities

Pre-authorisation required

Radiology 100% of MHR X-rays and ultrasounds MRI/CT scans covered for emergencies only

Pre-authorisation required

Pathology 100% of MHR Subject to Overall Annual Limit Pre-authorisation required

Mental health 100% of MHR Limited to PMBs at DSP Pre-authorisation required

Step-down facilities 100% of MHR R8 400 per family per annum Pre-authorisation required

Medical and surgical appliances

100% of MHR R3 500 per family per annum Post surgery and related to hospitalisation

Organ Transplant 100% of DSP Limited to PMBs at DSP Pre-authorisation required

Renal Dialysis 100% of DSP Limited to PMBs at DSP Pre-authorisation required

Oncology / Chemotherapy 100% of DSP Limited to PMBs at DSP Pre-authorisation required

Out

-of-

hosp

ital

/ D

ay-t

o-da

y B

enef

its

Network Providers available Prime Cure and CareCross

Prescribed medication 100% cover at NP

No annual limit applies Available at your chosen network provider - specific medicine list applies

Chronic medication 100% cover at NP

26 conditions coveredNo annual limit applies

Available at your chosen network provider - specific medicine list applies

General practitioners 100% cover at NP

No annual limit applies Consultations and proceduresAvailable at your chosen network provider

Basic dentistry 100% cover at NP

Examinations, preventative treatment, fillings and x-rays as per formulary

Available at your chosen network provider

Optical benefit 100% cover at NP

One eye test and pair of clear standard or bi-focal lenses with standard frame as per formulary per beneficiary every two years

Available at your chosen network provider

Subject to qualifying criteria

Pathology (Blood tests) 100% cover at NP

Specific list of pathology tests Available at your chosen network provider

Radiology (X-rays) 100% cover at NP

Specific list of black and white x-rays Available at your chosen network provider

Add

itio

nal /

Spe

cial

Ben

efit

s

Casualty / emergency visits 100% of MHR 1 visit per beneficiary per year. Maximum of 2 visits per family per year

Limited to R770 per event, 20% co-payment applies

Notification is required within 48 hours

Phone 0860 102 493

Specialists or physiotherapy visits

100% of MHR 2 visits per family per year limited to R700 per event. Maximum benefit of R1 150 per year, co-payment of 10% applies

Subject to referral by your chosen network provider and pre-authorisation

Phone 0860 102 493

HIV / Aids benefit

Anti-retroviral treatment

100% of MHR Maximum benefit of R22 700 per family per year

Members need to enrol on the Management Programme

Benefit includes: Lifestyle management, member education and anti-retroviral treatment

Aids related admissions

100% of MHR R24 200 per family per year

MHR Momentum Health Rate is the rate that Momentum Health sets for the reimbursement of claims

DSP Designated Service Provider - State facilities

NP Network Provider

PMBs Prescribed Minimum Benefits

Ingwe Option

* Scheme Rules require a co-payment if members use a

hospital outside the Ingwe and Access Network hospitals, but

the Scheme will waive this for student members on

these options.

A cost effective option for students, which allows you to choose your network provider (including Medicross) for day-to-day benefits.

Additional benefits are available for specialist visits, procedures and medicine.

How much will I pay? Member: R463 Adult Dependant: R463 Child Dependant: R304

Benefit Description Rate Benefit Notes

In-h

ospi

tal B

enef

its

Overall Annual Limit for all in-hospital benefits

100% of MHR No annual limit applies

Availble at any private hospital*

Pre-authorisation is required for all in-hospital treatment

Contact us on 0860 102 493 48 hours prior to admission date

If authorisation is not obtained, a co-payment will apply to all claims relating to the treatment, provided authorisation would have been granted according to the Rules of the Scheme. In the case of an emergency, you, someone in your family or a friend, may obtain authorisation within 72 hours of admission

Internal prosthesis 100% of MHR Intraocular lenses: R3 600 per beneficiary, maximum of 2 events. Other prostheses: R23 500 per beneficary per year - maximum of 2 events

Pre-authorisation required

Take-home medicine 100% of MHR Limited to 7 days supply per event Available on discharge from hospital

Maternity benefit 100% of MHR No annual limit applies

A 12 month pregnancy exclusion will apply to female members who are pregnant when joining the Scheme

Pre-authorisation required

In-hospital dental and oral benefits

100% of MHR Not covered Maxillo-facial trauma covered at State facilities

Pre-authorisation required

Radiology 100% of MHR X-rays and ultrasounds MRI/CT scans covered for emergencies only

Pre-authorisation required

Pathology 100% of MHR No annual limit applies Pre-authorisation required

Mental health 100% of MHR R12 100 per beneficiary per year Pre-authorisation required

Step-down facilities 100% of MHR R33 500 per family per year Pre-authorisation required

Medical and surgical appliances

100% of MHR R4 250 per family per annum Post surgery and related to hospitalisation

Organ Transplant 100% of DSP Limited to PMBs at DSP Pre-authorisation required

Renal Dialysis 100% of DSP Limited to PMBs at DSP Pre-authorisation required

Oncology / Chemotherapy 100% of DSP Limited to PMBs at DSP Pre-authorisation required

Out

-of-

hosp

ital

/ D

ay-t

o-da

y B

enef

its

Network Providers available Prime Cure, CareCross and Medicross

Prescribed medication 100% cover at NP

Unlimited with consultation, no co-payments

Available at your chosen network provider - specific medicine list applies

Chronic medication 100% cover at NP

Unlimited with no co-payments Available at your chosen network provider - specific medicine list applies

General practitioners 100% cover at NP

Unlimited at CareCross and Prime Cure R50 co-payment applies from the 11th visit at Medicross

Consultations and procedures - available at your chosen network provider

Basic dentistry 100% cover at NP

Examinations, preventative treatment, fillings and x-rays as per formulary

Available at your chosen network provider

Optical benefit 100% cover at NP

One eye test and pair of clear standard or bi-focal lenses with standard frame as per formulary per beneficiary every 2 years

Available at your chosen network provider

Subject to qualifying criteria

Pathology (Blood tests) 100% cover at NP

Specific list of pathology tests Available at your chosen network provider

Radiology (X-rays) 100% cover at NP

Specific list of black and white x-rays Available at your chosen network provider

Add

itio

nal /

Spe

cial

Ben

efit

s

Casualty / emergency visits 100% of MHR 1 visit per beneficiary per year. Maximum of 2 visits per family per year

Limited to R770 per event, 20% co-payment applies

Notification is required within 48 hours

Phone 0860 102 493

Specialists 100% of MHR 3 visits per beneficiary per year and a maximum of 5 visits per family per year.

Subject to pre-authorisation - Phone your chosen network provider

Prime Cure - 0861 665 665

CareCross - 0860 103 491

Medicross - 0860 225 569

HIV / Aids benefit

Anti-retroviral treatment

100% of MHR R22 700 per family per year Members need to enrol on the Management Programme

Benefit includes: Lifestyle management, member education and anti-retroviral treatment

Aids related admissions

100% of MHR R24 700 per family per year

Access Option

Mobisite - always in touch

Essential information you may need about your membership is available through your cellphone on our mobisite. From

checking your claims history, to finding a doctor and having instant access to emergency numbers, the mobisite is always

available and easy to use. Type in http://momentumhealth.mobi on your cellphone browser to visit the mobisite or go to

our website at www.ingwehealth.co.za to receive your mobisite link via sms.

Wow! benefits

— Apply for your membership online - visit www.ingwehealth.co.za

— Access to the Multiply Wellness Programme - visit www.multiply.co.za for more details

— Free access to the Go!Health rewards programme - visit www.go-health.co.za for more details

— Unlimited access to a 24-hour toll-free Health Advice line

— Unlimited ambulance services for emergency transportation through Netcare 911, including emergency evacuation

— Comprehensive HIV Wellness Programme

Tips on how to make your option work for you

— Phone 0860 102 493 for a pre-authorisation number if you need to go to hospital

— Your chosen network provider is the starting point for all consultations, medical care and medication

— Make an appointment to see the doctor (remember to phone to let the doctor know if you need to cancel it)

— Ask your doctor to only prescribe medicine on the medicine list (formulary)

— Ingwe members - phone 0860 102 493 for pre-authorisation for emergency / casualty visits, specialist and physiotherapy treatment

— Access members - phone 0860 102 493 for pre-authorisation for emergency / casualty visits and your network provider for specialist treatment

— Casualty, emergency and specialist benefits are limited – refer to the specific benefits of your chosen option

Contact usCustomer Care 0860 102 493

Hospital Pre-Authorisation 0860 102 493

Emergency Evacuation 082 911

Health Advice Line 0860 102 493

Prime Cure www.primecure.co.za 0861 665 665

CareCross www.carecross.co.za 0860 103 491

Medicross (Access Option only) www.medicross.co.za 0860 225 569

Go!Health www.go-health.co.za 0861 200 100

Europ Assistance SA 0861 127 332

Email Enquiries studenthealth@momentum.co.za

Website www.ingwehealth.co.za

This brochure is a marketing aid. On joining the Scheme, all members receive a detailed member brochure.

Scheme rules will always take precedence and are available on request.

_ _ 2 0M M Y Y _ _ 2 0D D M M Y Y M M0 1

_ _

1INGWE/HEALTH0051010E

International Student Application form 2010/2011

Broker Code Broker House

For office use only

Section 1: Application detailsPlease note: Compulsory documents to be submitted with the application form:

• Passport document • Letter of acceptance from academic institution • Proof of payment

New Application

Membershipstart date

Membershipend date Number of months

Provider’s practice numbers

Provider’s practice name

Group number

Section 2: Main member particulars: If you wish to add dependants - please complete an Addition of dependant application form

Passport Number Country in whichpassport was issued

Name of Institutionwhere studyingCampus Student Number

SurnameTitle Initials

First name

Address in South Africa

Postal code

Postal

Postal code

Residential

Cellphone number

E-mail address

Telephone No. Fax No.

CellphoneNetwork Provider

Section 3: Choose an option - Please indicate your chosen option

A mobicard will be sent to you via sms

Single Married Divorced Widowed Common LawMarital Status (mark with X where applicable)

Ingwe Option Access Option

How would you like to receive your welcome pack? Mail to member Send to campus Send to branch Other

Please specify

D D M M Y Y Y YDate of birth

Gender Male Female

Chronic and Day-to-day providerCare Cross

Prime Cure

Chronic and Day-to-day providerCare Cross

Medicross

Prime Cure

2

Section 4: Statement by applicant

Signature of applicant

_ _ 2 0D D M M Y YDateSignature of witness/broker

I hereby state that:(1) should I be enrolled as a member of Momentum Health, I will subject myself to the rules of Momentum Health. The information furnished herein is

completely true to the best of my knowledge and conviction. No relevant information has been omitted. If after my admission to Momentum Health,it is found that any statement of information furnished by me was knowingly and willfully inadequate or untrue, I agree to refund in full to MomentumHealth all payments which Momentum Health may have made on my behalf and to relinquish any claim to any benefits on the part of MomentumHealth. Should there by any deterioration or change in my state of health or in that any of my dependants before the date or event to be set byMomentum Health for the commencement of membership or the date of acceptance of this application by Momentum Health; or the date of receiptof the first contribution, (whichever date is the latest) Momentum Health will be entitled to reconsider the application and propose new terms of admissionor declare the membership null and void. Any monies paid to Momentum Health in terms of this membership, before Momentum Health is informedof the change, shall be forfeited and benefits paid by Momentum Health, shall immediately be refunded in Momentum Health.

(2) I irrevocably grant my permission to any physician, person or party who may be in possession of, or obtain information concerning my health, or thatof my dependants, to divulge such information to Momentum Health, also after my death.

(3) I undertake to pay any amount due to Momentum Health, on demand. Failure to pay any debt due to the Scheme may result in suspension of membership and/or handover to a third party for collection.

(4) I will call the designated service provider Netcare 911 on 082 911, when I need an ambulance.(5) I will call 0860 102 493 for Client Service and 0800 002 449 for any pre-authorised treatment inquiries. I hereby state that I understand the benefits

of my option.(6) I hereby grant permission to Momentum Health’s Administrators to forward any details relevant to my membership status, to me via SMS technology.(7) I hereby declare that I do not earn a taxable income of more than R500pm.(8) I understand that as a member of Momentum Health I do not qualify for any benefits in terms of pregnancy, confinement, HIV/AIDS and any related

costs as these benefits are excluded from my benefits in terms of a 12 month condition specific exclusion as per the Medical Scheme Act.

Section 5: Health Saver

Signature_ _ 2 0D D M M Y YDate

Sign below if you would like Momentum to activate your free Health Saver account. You can use this account as you see fit to make provision for additionalhealthcare expenses.

Name of bank: First National Bank Name of bank: Standard BankAccount holder: Momentum Health Student Account Account holder: Momentum HealthAccount no: 62127765371 Account no: 050 810 995Branch code: 223626 Branch code: 041026Branch name: Corporate Account Services: Durban Branch name: GreyvilleSwift code: FIRNZAJJ Swift code: SBAZAZAJJ00720535

Name of bank: Nedbank Name of bank: ABSAAccount holder: Momentum Health Account holder: Momentum HealthAccount no: 1469009021 Account no: 4060933128Branch code: 146905 Branch code: 632005Branch name: Commercial Northrand Branch name: KillarneySwift code: NEDSZAJJ Swift code: ABSAZAJJ

Banking details (Please use your passport number as reference when you deposit your contribution)