r501 per single member per month - getsavvi
TRANSCRIPT
R790 per family per month
R501 per single member per month
GetSavvi Health’s Primary Care
Plan option offers you ample day-
to-day benefits to keep you and
your family’s health in tip-top
shape.
Not only does the plan offer
excellent primary care benefits
like dentistry, selected medication,
preventative benefits and maternity
benefits, but it also offers you the
convenience of being able to see
your local GP whenever you need.
You can also enjoy a range of value-
added benefits like comprehensive
funeral cover, health advice and
discount coupons to ensure that
you get the most out of your policy.
AS A MEMBER OF THE PRIMARY CARE PLAN, YOU AND YOUR FAMILY HAVE ACCESS TO BENEFITS SUCH AS:
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Core Benefits• Unlimited doctors’ visits (managed)
• FeelBetterFast pharmacy solution allows you to see a
health professional fast
• Dentistry through our network providers
• Acute and chronic medication (subject to a formulary)
• Full maternity cover up to R30 000, including scans and
gynaecologists’ visits
• Netcare 911 emergency ambulance services
• Member Wellness Programme that includes unlimited HIV,
trauma and assault counselling
Value-added Benefits• Our unique 24-hour advice line via our health advisory
services
• Discount digital coupons for Dis-Chem, Shoprite, Checkers
and CheckersHyper
• Preventative benefits, including vaccinations and health tests
to help keep your family from getting sick
Funeral Benefit• Comprehensive Family Funeral Plan
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03WHY CHOOSE GETSAVVI HEALTH?
23HOW TO GET IN TOUCH
24GENERAL TERMS AND CONDITIONS
15VALUE-ADDED BENEFITS
• Preventative Benefits ..................................................... 16
• 24-hour Health Advisor ................................................... 17
• Discount Coupons ............................................................ 18
20OPTIONAL TOP-UP BENEFITS
• Unlimited Dentistry .......................................................... 20
• Optometry ......................................................................... 21
22OUR CLAIMS PROCESS
04CORE BENEFITS
• Day-to-day Benefits ......................................................... 04
1. Unlimited Doctors’ Visits (managed) .......................... 04
2. Basic and Emergency Dentistry .................................. 05
3. Medication ...................................................................... 06
4. Radiology ........................................................................ 07
5. Pathology ........................................................................ 07
6. Preventative benefits that form part of your
day-to-day cover ........................................................... 08
• Maternity Benefits ............................................................ 09
• FeelBetterFast .................................................................... 10
• Netcare 911 Emergency Services .................................. 12
• Member Wellness Programme ....................................... 13
• Unlimited HIV, Trauma and Assault Counselling ........ 14
19FUNERAL BENEFIT
• Comprehensive Family Funeral Plan ............................. 19
Contents
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WHY CHOOSEGetSavviHealth?
Value-added benefits like health
advice, STI medication, counselling
and monthly discount coupons.
Certified as the Best Medical
Insurance Provider 2019 in
SouthAfrica at the Healthcare &
Pharmaceutical Awards 2019.
Maternity cover up to
R30 000 at a private hospital.
No more waiting for your
membership card – get a digi-card
that you can print and present to
your service provider.
Over 2 500 network providers
available nationwide.
One cost covers the whole family.
Single member? Pay even less!
Unlimited children covered.
Unable to see your GP? Our
FeelBetterFast benefit gives you fast
access to a nurse or pharmacist at
a network pharmacy for symptom
screening and medication. And you
won’t have to make any co-payments!
We offer medication cover for
chronic illnesses such as HIV/
Aids, asthma, hypertension, type
1 and 2 diabetes, coronary artery
disease (CAD), hyperlipidaemia (high
cholesterol) and chronic obstructive
pulmonary disease (COPD).
Our Discount Coupons benefit will
help you save up to R1 250 on your
shopping from Shoprite, Checkers,
CheckersHyper and Dis-Chem.
Getting in touch with a GetSavvi
Health consultant is now easier
than ever and can be done by
contacting our Call Centre, email
or via our social media channels.
Regardless of what plan you’re signed
up with, all GetSavvi Health members
are covered by our Comprehensive
Family Funeral Plan that pays up to
R14 000 per member for natural
death, with double the payout
amount in the case of accidental
death.
Our Member Wellness Programme
cares for your mental well-being and
helps you cope with stress, anxiety,
post-traumatic stress disorder (PTSD),
addiction and more. It also includes the
HIV, Trauma and Assault Counselling
benefit for those in need of professional
assistance to help you cope.
CORE BenefitsThese are the essential services on your plan to support your healthcare needs and give you and your family peace of mind.
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Having access to your local GP is one of the first steps to good health. If you’re able
to see your doctor promptly, you could stop a potential illness from progressing
into something more serious.
For example, by treating the common cold or flu, you can prevent a secondary
infection like pneumonia or bronchitis.
With this benefit you’ll have access to unlimited visits (managed) per person per
annum on our network of more than 2 500 medical practitioners.
These consultations include minor procedures in the doctor’s rooms that are covered
in the tariffs for GP consultations.
*Terms and Conditions: GetSavvi Health offers unlimited GP visits to all members. However, to avoid abuse of this benefit, members will need to get authorisation after their sixth GP visit. Authorisation can be obtained by contacting the Call Centre on 0861 18 92 02.
DAY-TO-DAY BENEFITS
1. UNLIMITED DOCTORS’ VISITS (MANAGED)
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We understand that day-to-day benefits like
visiting your dentist can take a huge chunk from
your monthly expenses. That’s why our benefits
include basic and emergency dental procedures
from our list of network dentists:
• R1 650 per family per annum; doubles to R3 300
in the event of accidental injury. Basic, emergency
and accident treatment subject to a list of approved
procedures (designated dentists only).
• With our Primary Care Plan Top-up and Primary
Care Plan + Top-up options, the R1 650 limitation
becomes unlimited.
For even more dentistry benefits, members can
join our Primary Care Plan Top-up option for an
additional R177 per month. Read more on our
top-up option on page 17.
2. BASIC AND EMERGENCY DENTISTRY
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GetSavvi Health offers members
access to medication to improve their health.
HERE’S A LIST OF MEDICATION
COVERED IN OUR BENEFIT OPTIONS:
ACUTE MEDICATION
• R1 300 per family per annum (subject to a
formulary and dispensing vs non-dispensing
doctors’ rules).
CHRONIC MEDICATION
• We offer medication cover for chronic illnesses such as HIV/
Aids, asthma, hypertension, type 1 and 2 diabetes, coronary
artery disease (CAD), hyperlipidaemia (high cholesterol) and
chronic obstructive pulmonary disease (COPD).
GetSavvi Health has partnered with leading pharmacies: Chronic
medication can be collected from Medirite pharmacies only. Acute
medication can be collected from Medirite, Clicks and Dis-Chem
pharmacies. Ts & Cs apply.
3. MEDICATION
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4. RADIOLOGY
Members in need of having X-rays done have
access to a radiology benefit which is limited to
black-and-white X-rays only, and subject to a list
of covered X-rays. This benefit is only available
after referral by a network GP.
5. PATHOLOGY
In the case where your doctor needs to do
further blood tests, you can be assured of
pathology cover. This benefit is only available
after referral by a network GP and restricted
to a formulary of approved tests.
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Our Day-to-day Benefits include the following preventative screenings
and vaccinations:
• One pap smear per female aged 21 or older every three years.
• One Hepatitis A and B vaccination per member during the lifetime of
the policy.
• One pneumococcal (pneumonia) vaccination every five years for
members aged 65 or older, or individuals with a medically-proven
compromised immune system.
• One prostate-specific antigen screening for male members aged
50 years or older every two years.
* The Hepatitis A and B, and pneumococcal (pneumonia) vaccinations
will be deducted from the member’s acute medication limit of R1 300.
For further info on your Preventative Benefits, go to page 16.
6. PREVENTATIVE BENEFITS THAT FORM PART OF
YOUR DAY-TO-DAY COVER:
MATERNITY BENEFITSYour maternity benefit offers you even more peace of mind when
it comes to adding to your family.
Starting a family is a very special occasion. That’s why we at
GetSavvi Health want to make this time as seamless as possible in
terms of your medical needs.
Your maternity cover will include visits to the gynaecologist and
ultrasound scans as well as the costs related to birth.
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*Terms and Conditions: The waiting period for Maternity Benefits is 12 months from membership commencement. Members are required to pay up front and claim back from GetSavvi Health. Any provider may be used, provided that it’s a registered Board of Healthcare Funders (BHF) provider. Maternity benefits are only available to the main member or spouse, and do not apply to dependants.
YOU HAVE THE OPTION OF CHOOSING
ONE OF TWO BIRTH PROCEDURES:
Maternity benefits are only available to spouse,
and do not apply to dependants.
1 Cover of R20 000 for a normal birth. A normal birth is
defined as when the infant is born spontaneously (without
help) in the vertex position (head down) between 37 and
42 completed weeks of pregnancy.
2 Cover of R30 000 for a caesarean delivery (C-section).
A C-section is a surgical procedure used to deliver a
baby through incisions in the abdomen and uterus.
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FEELBETTERFAST
GetSavvi Health’s FeelBetterFast benefit offers you even more convenience
and peace of mind should you fall ill.
With this benefit we’ll help you nip any minor illness in the bud. If you don’t
have the time to schedule an appointment with your doctor or are unable to
get off sick from work, then FeelBetterFast will help you get better fast.
It offers access to pharmacy visits for a list of specified conditions, with
professional care and medication at your closest network pharmacy to get you
back on track quickly. This benefit is limited to 12 consultations per policy per
annum with a registered nurse or pharmacist, and free prescribed medication
according to a formulary. So you won’t have to make any co-payments.
HOW DOES FEELBETTERFAST WORK?
If you’re suffering from a minor ailment covered on the list, contact our Care
Centre on 0861 18 92 02. You’ll be directed to the closest network pharmacy
and issued with an electronic voucher via your cell phone. Visit the clinic at the
pharmacy and present the voucher to the nurse or pharmacist.
*Terms and Conditions: The waiting period for Maternity Benefits is 12 months from membership commencement. Members are required to pay up front and claim back from GetSavvi Health. Any provider may be used, provided that it’s a registered Board of Healthcare Funders (BHF) provider. Maternity benefits are only available to the main member or spouse, and do not apply to dependants.
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WHAT DOES THE FEELBETTERFAST BENEFIT COVER?
• Selected acute medication (subject to a formulary)
• Annual flu vaccination (to be administered by 30 September
each year)
• Treatment for a list of minor ailments
• Annual full health assessment with:
- Health tests such as blood pressure, body mass index (BMI),
HIV status, glucose levels, smoking status and cholesterol;
and
- A health report with your health test results, along with
accompanying information on how to keep your numbers in
check
• One tetanus vaccination per member every 10 years
This benefit is limited to 12 consultations per policy per annum with a
registered nurse or pharmacist, and free prescribed medication according
to a formulary.
WHAT TO DO IN A MEDICAL EMERGENCY:
1
2
3
Call Netcare 911 Emergency Services on 082 911.
If someone is calling on your behalf,
tell them to call 082 911.
Tell the Netcare 911 operator that you’re a GetSavvi
Health member – they will prompt you or the
caller through all the information they require to
get help to you fast.
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NETCARE 911 EMERGENCY SERVICES We have an ongoing partnership with one of South Africa’s leading emergency ambulance
service providers, Netcare 911, to guarantee you excellent ambulance services in the
case of an emergency.
This means that you have access to your Netcare 911 Emergency Services benefit 24 hours a
day, seven days a week.
In the unfortunate event of an emergency, you can contact the emergency number:
082 911. Netcare 911’s trained staff will assess your emergency over the phone, provide you
with assistance and then dispatch an air or road ambulance, whichever is most appropriate.
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The Member Wellness Programme offers
counselling and advice that’s voluntary,
private and confidential!
GetSavvi Health members, irrespective
of what plan you’re signed up for, have
access to counselling and/or treatment.
The aim of this benefit is to give you, as
a member, the means to apply a more
holistic approach to your health. This
means to acknowledge that your mind
directly affects your body and vice versa.
By taking steps for better mental wellness,
you could potentially help your physical
health too.
MEMBER WELLNESSPROGRAMME
WHAT IS THE PROGRAMME ABOUT?
GetSavvi Health offers members professional and confidential
counselling, support, awareness and advice on a range of topics.
Members can telephonically consult with psychologists, social
workers, dieticians, biokineticists (exercise experts), financial
coaches, debt counsellors and legal advisors to assist with:
• Personal issues
• Relationship problems
• Trauma/PTSD
• Financial counselling
• Legal advice
• Fitness advice
• Diet and nutrition
• HIV/Aids counselling (see page 14)
Note: You can use this benefit with confidence as our service
provider adheres to professional and strict regulations – and is
independent of GetSavvi Health – respecting confidentiality
and safeguarding your privacy.
USE THE BENEFIT BY CONTACTING US THROUGH
THE FOLLOWING CHANNELS:
1 Contact our Call Centre on 0861 18 92 02 and follow the voice prompts; or
2 Email us at [email protected]
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UNLIMITED HIV, TRAUMA AND ASSAULT COUNSELLING
GetSavvi Health’s Unlimited HIV, Trauma and Assault
Counselling benefit forms part of our Member Wellness
Programme (see page 13) and assists members who are
currently dealing with personal issues by:
• Reducing the high risk of HIV infection
• Managing emotional distress
• Eliminating effects of post-traumatic stress
• Offering genuine care and compassion
HOW TO USE THE BENEFIT:
1 Contact our Call Centre on 0861 18 92 02 and follow the voice prompts; or
2 Email us at [email protected]
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VALUE-ADDEDBenefitsThese support your core benefits by providing additional options and services for you and your family.
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What is preventative care and why is it important for members?
Preventative healthcare, or prophylaxis, are measures taken for the prevention of disease.
Disease, and specifically chronic conditions, are affected by numerous factors such as genetic predisposition, disease
agents and lifestyle choices.
GetSavvi Health firmly believes in the importance of preventative care by promoting healthier lifestyles. Therefore,
our FeelBetterFast and Preventative Benefits do just that: to detect and prevent the onset of disease and treatment
before it progresses.
PREVENTATIVE BENEFITS INCLUDE:
PREVENTATIVE BENEFITS:
*The Hepatitis A and B, and pneumococcal (pneumonia) vaccinations will be deducted from the member’s acute medication limit of R1 300.
Read more about your FeelBetterFast benefits on page 10 and 11. Page | 16
Benefit Who can get it When Where
Part of Day-to-day Benefits: 1 Pap smear Female aged 21 years or older Every 3 years Doctor’s office
Part of Day-to-day Benefits: 1 Pneumococcal (pneumonia) vaccination Members aged 65 or older, or
individuals with a medically-proven
compromised immune system
Every 5 years Doctor’s office
Part of Day-to-day Benefits: 1 Prostate-specific antigen screening Male members aged 50 years or older Every 2 years Doctor’s office
Part of Day-to-day Benefits: 1 Hepatitis A and B vaccination Per member Over the lifetime
of the policy
Pharmacy
FeelBetterFast Benefit: 1 Flu vaccination (to be administered by 30
September each year)
Per member Every year Pharmacy
Part of FeelBetterFast Benefit: Health tests, including blood pressure,
body mass index (BMI), HIV status, glucose levels, smoking status and
cholesterol. Includes health report with tailor-made tips on how to
improve health
Per member Every year Pharmacy
Part of FeelBetterFast Benefit: 1 Tetanus vaccination Per member Every 10 years Pharmacy
THIS BENEFIT INCLUDES ACCESS TO:
• Emergency medical advice: assist with first-aid until medical
help arrives.
• Assessing day-to-day symptoms: give information on illnesses
and guidance for home care.
• Important health knowledge: explaining medical terms,
results of tests, procedures and diet.
• Drug database: assist with information on a specific drug.
• Poisoning: addressing immediate and long-term needs,
with referral to a medical facility and dispatching an
ambulance for a critical patient.
• Health counselling: provide understanding of chronic
ailments such as cancer, HIV/Aids, diabetes or asthma, etc.
• Stress management: provide counselling, advice and
relaxation techniques.
• Trauma debriefing: after a debrief, you’ll be invited to call back
and be referred to a professional trauma counsellor if needed.
To make use of this benefit, simply call 082 911 and
ask to speak to a nurse. The nurse will then assess
your symptoms and provide you with medical advice
and what steps need to be taken.
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If you or a member of your family is
feeling ill, it’s best to always speak to a
professional instead of searching for
your answers elsewhere. We offer a
Health Advisor benefit that will give you
quick and reliable health-related advice.
You’ll get access to professional
assistance for any of your health
queries 24 hours a day, 365 days a
year, offered in the majority of the
official South African languages.
24-HOURHEALTH ADVISOR
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Coupons vary each month for a range of in-store products from
tinned foods and fresh produce to cleaning and beauty products.
DISCOUNT COUPONSAs a GetSavvi Health member, you’ll be able to cut your grocery andnon-medical pharmacy expenses by up to R1 250 with our list of monthly discount coupons. Each coupon is redeemable up to five times.
HOW DOES IT WORK?
We’ll send you a monthly SMS to your valid South African mobile number.
Click the link to the mobi website where you’ll have access to the digital
discount coupons.
All retrieved coupons will be valid until the end of the month.
1 MONTH
REDEEM AT:
You’ll then provide the cashier with the digital coupons once all of
your products have been rung up and the discounts will be deducted
automatically.
In the unfortunate event of losing a loved one, the last
thing you want to be burdened with is high funeral costs.
With GetSavvi Health’s Comprehensive Family Funeral
Plan, you’ll be assured complete cover for death and
the funeral for you and your family. This benefit will
provide you with much-needed funds to plan a funeral
and honour your loved one.
COMPREHENSIVEFAMILY FUNERAL PLAN
Participant Death Cover
Main Member (aged 18-60) R14 000 (R28 000 in case of
accidental death)
Spouse R14 000 (R28 000 in case of
accidental death)
Children (aged 14-21) R14 000
Children (aged 6-13) R7 000
Children aged up to 5 years
(including stillborn)
R3 500
FUNERAL COVER BENEFITS FOR YOU, YOUR SPOUSE AND CHILDREN:
FUNERAL Benefit
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Optional TOP-UPBenefitsOur top-up benefits are available as an optional extra for just R177 per month for members of the Primary Care Plan who’d like even more primary healthcare cover.
UNLIMITED DENTISTRY
TOP-UP BENEFIT LIMIT • The R1 650 basic and R3 300 emergency dental benefits’
limitations are lifted and the member (including family) now
has access to unlimited dental visits. Treatment subject to a
list of approved procedures (designated dentists only).
TOP-UP CONSULTATIONS• Members get unlimited dentist consultations on the top-up
dentistry option.
• Consultations are covered according to limitations of a clinical
nature that are generally accepted in the dental market.
TOP-UP FLUORIDE TREATMENT• Covers children under the age of 12. One fluoride treatment
every six months.
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CONSULTATION/EYE TEST One consultation/eye test for one member per family
every 24 months.
EYEGLASS FRAMEOne pair of Preferred Provider Network (PPN) spectacle
frames for one member per family every 24 months.
SINGLE VISION LENSESOne pair of single vision lenses for one member per
family every 24 months.
BIFOCAL One pair of bifocal lenses for one member per family
every 24 months.
PPN EXPLAINEDPreferred Provider Network (PPN) is an affiliate of GetSavvi
Health which offers an extensive optical network with
more than 2 500 providers contracted countrywide.
OPTOMETRYThe top-up optometry benefit offers the member access to the following benefits:
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OUR CLAIMS Process1
Contact our claims
team on 0861 18 92 02 and our
professionally-trained agents will
assist you step by step.
2
Log on to our website at
www.getsavvi.co.za via the
internet or smartphone, click the
“Login” tab and submit your claim
immediately online.
3
Send claims via email to
Our claims team will handle all claims during office hours from
8am to 5pm on weekdays and 9am to 1pm on Saturdays and
public holidays. All claims submitted after hours will be handled
the following working day. All valid claims will be processed and
paid for at predetermined and negotiated scheme rates.
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Now you have several easy ways to make a claim:
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HOW TO GETIn Touch
WWW.GETSAVVI.CO.ZA
0861 18 92 02
PO BOX 378, CAPE GATE, 7562
@GETSAVVIHEALTH
@GETSAVVI
the same trigger event should be claimed under the one benefit. 2.8 Where a member is covered in terms of a statutory body such as the Compensation for Occupational
Injuries and Diseases or the Road Accident Fund or their successors in title or assigns, in relation to an accident, the insurer will only be liable for amounts that the member may be liable for due to shortfalls incurred and up to the maximum accident benefit amount.
2.9 If a member’s hospital illness benefit distinguished between tariffs for normal ward and ICU/High Care, the split of the tariffs will be based on the number of days the member has been in hospital as from the original admission date. For example, if the member has been in ICU for three days, day one to three will be calculated on ICU/High Care tariffs and the member’s normal ward benefit will be calculated from day four onwards. If the member was admitted to the normal ward for five days and then transferred to ICU/High Care for another five days, then the benefit will be calculated as follows: Day one to five based on normal ward tariffs and days six to ten based on ICU/High Care tariffs. If the member is transferred back to normal ward, the benefit will be calculated as from day 11 on normal ward tariffs. Limited to the member’s annual overall limits.
2.10 With regards to an illness: a recurrence of any illness will only be considered a separate illness if six months have elapsed from the date of onset of the preceding illness and which has a definite diagnosis and treatment plan.
2.11 The following conditions are excluded from any illness and hospitalisation benefit: 2.11.1 Kaposi’s sarcoma; 2.11.2 Pneumocystis carinii; 2.11.3 Tuberculosis; 2.11.4 CMV; 2.11.5 Cryptococcal meningitis; 2.11.6 Cryptosporidium; 2.11.7 Disseminated herpes/shingles. 2.12 No claim will be admitted in terms of this policy if the event giving rise to the claim is caused directly or
indirectly by, or is in any way attributable to, any of the following: 2.12.1 The willing participation by the member in any of the following: 2.12.1.1 an act of war (whether war is declared or not); 2.12.1.2 military action; 2.12.1.3 riot or unlawful strike; 2.12.1.4 insurrection; 2.12.1.5 civil commotion; 2.12.1.6 usurpation of power; 2.12.1.7 martial law; 2.12.1.8 terrorism; and 2.12.1.9 any usage of nuclear, chemical and biological weapons, device or agent. 2.12.2 A disease, epidemic or pandemic; 2.12.3 An act of government; 2.12.4 Any act or deed by the member deliberately committed in violation of any law as well as any other
insured person under the policy, including but not limited to a minor child, where his/her parent and/or legal guardian knowingly allows such child to participate in any act which constitutes a violation of any law;
2.12.5 Self-inflicted injury or self-inflicted illness, whether intended or not, or voluntary exposure to danger or obvious risk of injury. Any injury or disease which is caused partly by the actions or omissions of the insured, but in conjunction with the action or omission of some other party or some other contributory factor, will fall outside the ambit of the above exclusion.
3 DISCLOSURE 3.1 GetSavvi Health is an authorised Financial Services Provider, FSP No. 44283, underwritten by African
Unity Life Ltd, a licenced life insurer and authorised Financial Services Provider, FSP No. 8447. GetSavvi Health is a medical insurance plan, not a medical aid scheme, and adheres to the long- and short-term insurance acts. Ts & Cs apply.
4 COMPLAINTSShould you not be satisfied with the product purchased, you may lodge a formal complaint with:
GetSavvi Health by calling us on 0861 189 202 or via email to [email protected].
GetSavvi Health is committed to service excellence and fully subscribes to the terms and conditions of the Policyholder protection Rules. The long-term insurance Ombudsman:
Telephone number: 021 657 5000Fax number: 021 674 0951Share call: 0860 103 236Email: [email protected] address: Private Bag X45, Claremont, 7735
The FAIS Ombudsman:Postal Address: PO Box 74571, Lynnwood Ridge, 0040Telephonic Number: 0860 324 766Fax Number: 012-348-3447Email Address: [email protected]
5 DAY-TO-DAY BENEFITS*Day-to-day benefits not applicable to GetCare Plan 5.1 GP Visits 5.1.1 Visits are unlimited but managed per insured person per annum. 5.1.2 Pre-authorisation is required after the sixth visit. GetSavvi Health reserves the right to reject pre-authorisation requests. 5.1.3 DISCLAIMER: Where the company suspects abuse of the benefit by any participating member,
the company may take steps to limit the usage of the benefit, increase premiums or both. In these circumstances, the company will provide the participating member with a 31-day notice in writing.
5.1.4 The member is responsible for checking the network list via either the website or the Call Centre, as the network list may change from time to time. The company cannot be held liable for visits to non-network affiliated providers, and the member will be liable for payments for such visits. The scheme will not be responsible for claims received after 120 days from the service date due to service provider or member negligence.
5.1.5 General waiting period: A three-month waiting period from the date of the policy commencement applies to GP visits and procedures, dentistry, radiology, pathology and acute prescribed medication, except: emergency medical services (no waiting period); chronic medication (12-month waiting period); and maternity (12-month waiting period).
5.1.6 Limitations: These benefits are only available to members: - under the age of 60 for the principal member and his/her spouse; and
BENEFIT TERMS AND CONDITIONS: Waiting Periods, Exclusions and Limitations
These are the standard Terms and Conditions relating to your chosen plan. Please read them carefully, as by entering into a contract with the company you will be bound hereto.
1 CLAIMS 1.1 We have a standard 120-day submission period for all claims. Any claim submitted after this period will
be rejected as stale. Members and designated service providers have a total of 90 days to query a claim from the original remittance date. Any claims queried after this time period will be regarded as a stale query. Please note that all stale submissions and queries will be the member’s liability. It is the member’s responsibility to follow up on claims.
1.2 The notification period from the date of the event should be within four calendar months from the date of the claim event for day-to-day and hospital benefits.
1.3 Submission of all required documentation to assess the claim should be within four calendar months from the date of the claim event for day-to-day and hospital benefits.
1.4 The member, if physically able to do so, should notify GetSavvi Health within 48 hours after admission to hospital.
1.5 GetSavvi Health administers the issuing of FeelBetterFast vouchers upon request, limited to 12 visits per family per annum.
1.6 For HIV, Trauma and Assault Counselling benefits, contact our Call Centre on 0861 18 92 02 and follow the voice prompts for 24-hour assistance.
2 GENERAL EXCLUSIONS AND LIMITATIONS 2.1 An insured person may not be covered for more than one policy under this insurance category. 2.2 The policyholder will not be entitled to any benefits if admission is required for the purposes of
investigative procedures or any other investigation only, unless specifically provided for in this agreement.
2.3 This policy does not cover any admission to hospital as a result of or relate to complications or conditions arising as a result of pregnancy or during childbirth during the first 12 months from the commencement date or any reinstatement date. Admission to hospital which is a result of or relate to complications or conditions arising as a result of pregnancy will be part of the maternity benefit and will be subject to the maximum limit as set out on the maternity benefit.
2.4 The insurer will not be liable for any claims: 2.4.1 caused by suicide or attempt thereof, self-inflicted injury or wilful exposure to danger (unless in
an attempt to save a human life); 2.4.2 in respect of expenses arising out of routine physical or other examinations where there is no
objective indications or impairment in normal health; 2.4.3 in respect of obesity, elective procedures, elective cosmetic or plastic, corrective optical
and laser surgery or treatment and the costs resulting therefrom, except in the case of bodily reconstruction as a direct result of an injury sustained in an accident;
2.4.4 in respect of premature childbirth unless the expected date of birth is later than nine consecutive months after inception of insurance;
2.4.5 for a newborn baby before the baby has been discharged with a clean bill of health, after which a newborn baby will be covered. Members have 12 months after the birth of the baby to obtain the bill of health;
2.4.6 resulting from a member refusing medical treatment recommended by a physician or medical practitioner;
2.4.7 resulting from a member unreasonably or wilfully neglecting or failing to seek and remain under the care of a medical practitioner;
2.4.8 for admission to hospital at the member’s own choosing which has no connection with any injury, illness or dread disease other than by recommendation by a qualified physician;
2.4.9 for admission to hospital for the investigation of pain and pain-related conditions and treatment which in this context include bed rest, traction, physiotherapy, spinal blocks, medication or intravenous medication;
2.4.10 where the member did not take all reasonable precautions to prevent accidents and do not comply with all statutory requirements and regulations;
2.4.11 resulting from the use of alcohol, drugs or narcotics unless administered by, or prescribed by, and taken in accordance with the instructions of a medical professional (other than himself);
2.4.12 caused by the use of nuclear, biological, chemical or explosive weapons or arising from exposure to, or contamination by, atomic energy and/or nuclear fission or reaction;
2.4.13 for injuries sustained while any person driving a vehicle or motorcycle is under the legal driving age or is not authorised or qualified to drive such a vehicle or motorcycle;
2.4.14 caused while travelling by air other than as a passenger and not as a member of the crew nor for the purpose of any trade or technical operation thereon or therein;
2.4.15 resulting from participation in a hazardous or professional sport/activity; 2.4.16 for any mental illness, mental disability, mental impairment and psychopathic disorders, all
forms of depression, major affective disorders, psychotic and neurotic conditions, as well as all stress and anxiety-related disorders, other than those caused by an accident as defined in this insurance;
2.4.17 for mountaineering or rock climbing necessitating the use of ropes or guides, potholing, hang gliding, skydiving, riding or driving in a race or rally, quad biking, off-road motorcycle riding, underwater activities involving the use of artificial breathing apparatus unless the member has an open water diving certificate or is diving with a qualified instructor to a depth no greater than 30 metres and/or similar activities, unless agreed by the insurer;
2.4.18 for perpetrating an intentional unlawful act in terms of South African Law; 2.4.19 for any gradually operating cause; 2.4.20 for the treatment of any sexual transmitted disease, unless as a result of a crime that has been
reported to the South African Police Services; 2.4.21 for services rendered to a member by a person not registered with the South African Medical and
Dental Council and/or the South African Health Professions Council; 2.4.22 for treatment of infertility or the artificial insemination of a person as defined in the Human Tissues
Act (Act 65 of 1983) or any amendment thereto or replacement thereof; 2.5 If the consequences of an accident shall be aggravated by any condition or physical disability of
the member which existed before the accident occurred, the amount of any compensation payable under this insurance in respect of the consequences of the accident shall be the amount which it is reasonably considered would have been payable if such consequences had not been so aggravated.
2.6 In addition to the above, qualified medical advice shall be sought and followed promptly on the occurrence of any bodily injury, dread disease or illness and the insurer shall not be liable for any part of any claim which in the opinion of the medical adviser arises from the unreasonable or wilful neglect or failure of a member to seek and remain under the care of a qualified member of the medical profession.
2.7 Unless specifically allowed for, compensation for the same trigger event or illness may not be claimed under more than one benefit. For example, should the member be diagnosed with a dread disease and is hospitalised later due to an illness that resulted directly from the dread disease, all benefits related to
- under the age of 21 for children. 5.1.7 A family is defined as a Principal Insured and a spouse, married either by civil or common law, and children
either natural, step, adopted or fostered. No limitation exists on the amount of children. 5.1.8 GP consultations relating to mental disorders/illnesses and/or as a result of the influence of drugs
or narcotics will not be covered. 5.1.9 One Hepatitis A and B vaccination per member during the lifetime of the policy. 5.1.10 The Hepatitis A and B, and pneumococcal (pneumonia) vaccinations will be deducted from the
member’s acute medication limit of R1 300. 5.1.11 The list of GP procedures are as follows:
GP PROCEDURES
Codes Description
In-room Procedures
0190 Consultation/visit of new or established patient
0191 Consultation/visit of new or established patient
0192 Consultation/visit of new or established patient
0300 Stitching of wound (with or without local anaesthesia), including normal aftercare
0301 Additional wound stitching at same session (each)
0307 Excision and repair by direct suture; excision nail fold or other minor procedure of similar magnitude
0255 Drainage of subcutaneous abscess onychia, paronychia, pulp space or avulsion of nail
0259 Removal of foreign body superficial to deep fascia (except hands)
0887 Limb cast (excluding aftercare)
The following procedures performed in the rooms are included in the consultation fee:
0201 Cost of material
0202 Setting of sterile tray
0206-0207 Infusions
0222-0246 Integumentary system
0316 Fine needle aspiration
0317 Aspiration of cyst or tumour
1037 Diathermy nose under local
1136 Nebulisation
1186-1192 Lung function test
1228-1229 ECG Paediatric
1232-1235 ECG
2125-2131 Destruction of condylomata chemo, cryo or electro
2271-2272 Vulva removal tag, polyp or superficial benign lesion
2316-2318 Destruction condylomata
2392 Cryo- or electro cautery of cervix
2399-2404 Biopsy cervix
2705 TENS
3171 Excision meibomian cyst eyelid
3287 Injection ligaments and joints
3304 Other physical treatments
Any diagnostic pathology test in surgery
5.2 Basic and Emergency Dentistry 5.2.1 The benefit for basic and emergency dentistry per family per annum comprises: 3.2.1.1 basic dentistry with a limit of up to R1 650; with 3.2.1.2 double the benefit on accidental injury to the maximum of R3 300. 5.2.2 Emergency dental care is defined as dental services rendered for the purpose of incidents requiring
immediate attention. 5.2.3 The waiting period for emergency and basic dentistry is three months. 5.2.4 The list of dental procedures are as follows:
LIST OF DENTAL PROCEDURES – STANDARD
Codes Description Limitations
Consultation
8101 Full mouth examination charting and treatment plan
One per annum with a six-month interval
8104 Examination or consultation for a specific problem, not requiring charting and treatment planning
Maximum one per visit
Diagnostic Codes
8107 Intra-oral radiographs per film Maximum two per visit
8112 Intra-oral radiographs per film Maximum two per visit
8109 Infection control Maximum two per visit
8110 Provision of heat or vapour sterilised and wrapped instrumentation
Maximum one per visit
8145 Local anaesthetic per visit Maximum one per visit
Preventative Codes
8159 Scale and polish One per annum with a six-month interval
8161 (8162)
Fluoride treatment Once every six months per member younger than 12 years
8201 Extraction – each additional tooth in the same quadrant
Maximum three non-surgical extractions per insured per annum. Four or more require pre-authorisation
Emergency Codes
8132 Pulp removal (emergency root canal treatment)
One per member per annum
Restoration Codes
8341 (8367)
Amalgam – one surface Pre-authorisation and X-rays required for:• More than four restorations per year(especially anterior teeth)• Two, three, four or more surface fillings per visit• More than two anterior restorations per visit• Multiple fillings on an anterior tooth onthe same service date• Posterior teeth restorations cannot beperformed across the midline. Deviationswill only be covered if pre-authorised• Any three or four surface fillings onwisdom teethGeneral Rules:• Restoration code per tooth number in anine-month period will not be covered:• Repairing of teeth damaged due tobruxism, toothbrush abrasion, erosionand fluorosis• Replacement of non-carious amalgamwith resin• Fillings on non-functional wisdom teeth
8342 (8368)
Amalgam – two surfaces
8343 (8369)
Amalgam – three
8344 (8370)
Amalgam – four or more surfaces
8351 Resin – one surface
8352 Resin – two surfaces
8353 Resin – three surfaces
8354 Resin – four surfaces
Surgical Incisions
8731 Incision and drainage of abscess – intra-oral
9011 Incision and drainage of abscess – intra-oral (pyogenic)
9013 Incision and drainage of abscess – intra-oral (pyogenic)
5.3 Acute Medication 5.3.1 Subject to a list of medicines (medicine formulary) approved by the service provider for acute illnesses
and formulary reference pricing (FRP), as amended from time to time and available through the pharmacies or dispensing general practitioners identified by the service provider.
5.3.2 Limited to R1 200 per family per annum only from non-dispensing doctors who form part of the GetSavvi Health network.
5.3.3 Acute medication prescribed by a dentist or dispensing doctor will not be covered.
5.4 Chronic Medication 5.4.1 The chronic medication benefit is limited to the principal member. 5.4.2 A 12-month waiting period will apply from the date of the policy commencement. 5.4.3 List of chronic medication formulary:
CHRONIC MEDICATION
Active Ingredient Item
Diabetes Mellitus Type 1
Insulin HumalogNovorapid
Diabetes Mellitus Type 2
Glibenclamide Glycomin – 5mgSandoz Glibenclamide – 5mg
Gliclazide Adco-Glucomed – 80mgDiaglucide – 80mgGlygardDyna-Glicazide – 30mg
Glucose Strips Glucoplus stripsSolus (Cipla) strips
HIV/Aids
Tenofovir, Lamivudine, FTC –Emtricitabine, Efavirenz, Ritonavir
Atroiza combinationOdimune combinationTribuss combination
Hypertension
Amlodipine Amlodac – 5mg; 10mgPD Amlodipine – 5mgLomanor – 5mg; 10mgPendine – 5mg; 10mg
Atenolol Sandoz Atenolol – 50mg; 100mgTen-Bloka – 50mg; 100mg
Bisoprolol Bilocor – 5mg; 10mgAdco-Bisocor – 5mg; 10mgBisohexal – 5mg; 10mg
Captopril Adco-Captomax – 25mg/50mgMylan Captopril – 25mg/50mg
Carvedilol Carvetrend – 6.25mg; 12.5mg; 25mgVediblok – 6.25mg; 12.5mg
Diltiazem Adco-Zildem – 60mgAdco-Zildem – 180mg; 240mg
Doxazosin CardugenAdco-Doxazosin
Enalapril Enap – 5mg; 10mg; 20mgSandoz-Enalapril – 5mg; 10mg; 20mgAlapren – 5mg; 10mg; 20mg
Enalapril and diuretics Enap CO – 20/12.5mgPharmapress CO – 20/12.5mg
Felodipine Felodipine-Hexal – 5mg; 10mg
Furosemide Mylan-Furosemide – 40mgNuzak
Indapamide Cipla-Indapamide – 2.5mgDaptril – 2.5mg
Lisinopril Sinopren – 5mg; 10mg; 20mg
Lisinopril and diuretics Adco-Zetomax CO – 10/12.5mg; 20/12.5mgLisoretic – 10/12.5mg; 20/12.5mg
Losartan Zartan 100mg – 100mgCiplazar – 100mg
Losartan and diuretics Hytenza CO – 50/12.5mg; 100/25mgZartan CO – 50/12.5mg; 100/25mg
Methyldopa Hypotone: Sandoz Methyldopa – 250mg
Perindopril Ciplasyl – 4mg; 8mgPearinda – 4mg; 8mgPrexum – 5mg
Propranolol Purbloka – 10mg; 40mg
Quinapril Accumax – 10mg; 20mg
Spironolactone Aldactone – 25mgSpiractin – 25mg
Verapamil Vasomil – 40mg; 80mgVerahexal SR – 240mg
Asthma
Beclometasone Beclate 200 dose – 100mcg; 200mcg
Salbutamol Venteze CFC-free 200 dose – 100mcg; Asthavent
Salmeterol and other drugs Serevent – 25ug; 50ugSereflo – 25/50; 25/125; 25/250Foxair accuhaler 60 dose – 50/100; 50/250; 50/500
Theophylline Sandoz Theophylline Anhydrous – 200mg; 300mg
Hyperlipidaemia (High Cholesterol)
Bezafibrate Sandoz Bezafibrate 400 mg CR tabs
Atorvastatin Calcium Aspavor – 10mg; 20mg; 40mg; 80mg tabsAdco-Atorvastatin – 10mg; 20mg; 40mg tabsDynator – 10mg; 20mg; 40mg; 80mg tabs
Simvastatin Simvacor – 10mg; 20mg; 40mg tabsAdco-Simvastatin – 10mg; 20mg; 40mg tabsCipla-Simvastatin – 10mg; 20mg; 40mg; 80mg tabs
Coronary Artery Disease (CAD)
Propranolol HCl Pur-Bloka – 10mg; 40mg tabs
Amlodipine Besylate Sandoz Atenolol – 50mg; 100mg tabsTen-Bloka – 50mg; 100mg tabs
Amlodipine Besylate Pendine – 5mg; 10mg tabsLomanor – 5mg; 10mg tabsAmlodac – 5mg; 10mg tabs
Diltiazem HCl Adco-Zildem – 60mg; 180mg; 240mg tabs
Felodipine Felodipine-Hexal – 5mg; 10mg tabs
Verapamil HCl Vasomil – 40mg; 80mg tabs
Chronic Obstructive Pulmonary Disease (COPD)
Albuterol Sulfate Inhal Aero Venteze CFC-free 200 dose – 100mcgAsthavent Inh – 200 doseAsthavent – 200 dose Ecohaler
Salmeterol Xinafoate Serevent Inhaler – 60 dose; 120 doseSerevent Disc – 50mcg/Bl Pa
Fluticasone-Salmeterol Sereflo 25/50 Gentlehaler – 120 doseFoxair 25/50 Inh – 120 doseSereflo 25/50 HFA SynchrobreatSereflo 25/125 Gentlehaler – 120 doseFoxair 25/125 Inh – 120 doseSereflo 25/125 HFA Synchrobrea
Theophylline Sandoz Theophylline Anhydrous – 200mg; 300mg
5.5 Radiology (X-rays) 5.5.1 Access to basic radiology: black-and-white diagnostic X-rays on referral by a general practitioner
appointed by the service provider at one or more of the consultations referred to under General Practitioners if required.
5.5.2 Subject to a list of X-ray procedures approved by the service provider, available through a specialist radiologist. 5.5.3 The waiting period for radiology is three months. 5.5.4 List of X-ray codes:
LIST OF X-RAYS
Codes Description Left/right
30110 chest, two views, anteroposterior (AP) and lateral
64100 forearm left
64105 forearm right
65130 wrist left
65135 wrist right
65100 hand left
65105 hand right
65120 finger
65140 scaphoid left
65145 scaphoid right
62100 humerus left
62105 humerus right
63100 elbow left
63105 elbow right
72100 knee, one or two views left
72105 knee, one or two views right
72120 knee including patella left
72125 knee including patella right
72140 patella left
72145 patella right
71100 femur left
71105 femur right
73100 lower leg left
73105 lower leg right
74100 ankle left
74105 ankle right
74120 foot left
74125 foot right
74130 calcaneus left
74135 calcaneus right
74145 toe
5.6 Pathology 5.6.1 Only available after referral by a network GP and restricted to a formulary of approved tests. 5.6.2 Access to basic pathology: diagnostic pathology tests on referral by a general practitioner appointed by
the service provider at one or more of the consultations referred to under General Practitioners if required. 5.6.3 Subject to a list of basic pathology tests approved by the service provider. 5.6.4 The waiting period for pathology is three months. 5.6.5 The list of pathology tests approved are limited to the following:
PATHOLOGY TESTS
Codes Description
4009 Bilirubin: total
4130 Aspartate aminotransferase (AST)
4131 Alanine aminotransferase (ALT
4001 Alkaline phosphatase
4027 Cholesterol: total
4147 Triglyceride
4025 Cholesterol, HDL/LDL, triglycerides
4113 Potassium
4114 Sodium
4151 Urea
4032 Creatinine
4057 Glucose
4064 HbA1c
3865 Parasites blood smear
3883 Concentration techniques for malaria
3762 Haemoglobin estimation
3785 Leucocyte: total count
3743 Erythrocyte sedimentation rate
3755 Full blood count
3797 Platelet count
4188 Urine dipstick: per stick
3947 C-reactive protein
3948 Qualitative Kahn, VDRL or other flocculation
4352 Occult blood: chemical test
3816 CD4 Count
3882 Occult blood: Monoclonal
4026 LDL Cholesterol
4028 HDL Cholesterol
5.7 Optometry and Dentistry Top-up (only available on top-up plans) 5.7.1 A six-month waiting period for optometry and three-month waiting period for dentistry applies from
commencement of the top-up option. 5.7.2 Optometry Top-up 5.7.2.1 Where a member has selected the Optometry benefit, all members on the plan will have access,
but only one member can use it at a time within a two-year period. The benefit is limited to the use of a Preferred Provider Network (PPN) affiliated optometrist (contact the Call Centre to confirm available optometrists) and the following once every 24 months:
5.7.2.2 Top-up benefits include (one member per family every 24 months): 4.7.2.2.1 One consultation (including eye test) 4.7.2.2.2 One PPN frame 4.7.2.2.3 One pair of single vision/bifocal lenses 5.7.2.3 Please note that GetSavvi Health does not cover any of the following: 5.7.2.3.1 Contact lenses 5.7.2.3.2 Non-PPN frames 5.7.2.3.3 Lens enhancements, including but not limited to: 5.7.2.3.3.1 anti-glare; 5.7.2.3.3.2 tinting; and/or
from the Commencement Date or any Reinstatement Date. Admission to hospital which is a result or relate to complications or conditions arising as a result of pregnancy will be part of the maternity benefit and will be subject to the maximum limit as set out on the maternity benefit.
6.1.5 The Insurer will not be liable for any claims: 6.1.5.1 was caused by suicide or attempt thereat or self-inflicted injury or wilful exposure to danger
(unless in an attempt to save human life); 6.1.5.2 in respect of expenses arising out of routine physical or other examinations where there is
no objective indications or impairment in normal health; 6.1.5.3 in respect of obesity, elective, elective cosmetic or plastic, corrective optical and laser surgery
or treatment and costs resulting therefrom except in the case of bodily reconstruction as a direct result of an Injury sustained in an Accident;
6.1.5.4 in respect of premature childbirth unless the expected date of birth is later than 9 (nine) consecutive months after inception of insurance;
6.1.5.5 The new born baby born in the first twelve months, will be covered after the baby has been discharged with a clean bill of health;
6.1.5.6 resulting from an Insured refusing medical treatment recommended by a physician or medical practitioner;
6.1.5.7 resulting from an Insured unreasonably or wilfully neglecting or failing to seek and remain under the care of a medical practitioner;
6.1.5.8 resulting from, whilst in Hospital at the Insured Person’s own choosing which has no connection with any Injury, Illness or Dread Disease or in Hospital other than by recommendation by a qualified physician;
6.1.5.9 resulting from, whilst in Hospital for the investigation of pain and pain related conditions and treatment in this context includes bed rest, traction, physiotherapy, spinal blocks, medication or intravenous medication;
6.1.5.10 where the Insured did not take all reasonable precautions to prevent Accidents and do not comply with all statutory requirements and regulations;
6.1.5.11 was caused by, or as a result of, the influence of alcohol, drugs or narcotics upon such Insured Person unless administered by, or prescribed by, and taken in accordance with the instructions of a member of the medical profession (other than himself);
6.1.5.12 was caused by the use of nuclear, biological, chemical or explosive weapons or arising from exposure to, or contamination by, atomic energy and/or nuclear fission or reaction;
6.1.5.13 if injuries sustained whilst any person driving a vehicle or motorcycle is under the legal driving age, or is not authorized or qualified to drive such a vehicle or motorcycle;
6.1.5.14 was caused whilst traveling by air other than as a passenger and not as a member of the crew nor for the purpose of any trade or technical operation thereon or therein;
6.1.5.15 was caused whilst participating in a hazardous or Professional Sport/activity; 6.1.5.16 was caused by any mental illness, mental disability, mental impairment and psychopathic
disorders, all forms of depression, major affective disorders, psychotic and neurotic conditions, as well as all stress and anxiety related disorders, other than those caused by Accident as defined in this Insurance;
6.1.5.17 while it was caused by mountaineering or rock climbing necessitating the use of ropes or guides, potholing, hang gliding, sky diving, riding or driving in a race or rally, quad biking, off-road motorcycle riding, underwater activities involving the use of artificial breathing apparatus unless the Insured Person has an open water diving certificate or is diving with a qualified instructor to a depth no greater than 30 meters and/or similar activities, unless agreed by the Insurer;
6.1.5.18 was caused whilst the Insured Person is perpetrating an intentional unlawful act in terms of South African Law;
6.1.5.19 was caused by any gradually operating cause; 6.1.5.20 for the treatment of any sexual transmitted disease, unless as a result of a crime that has
been reported to the South African Police Services; 6.1.5.21 for services rendered to an Insured Person by a person not registered with the South African
Medical and Dental Council and/or the South African Health Professions Council; 6.1.5.22 was caused by, directly or indirectly arising from, treatment of infertility or the artificial
insemination of a person as defined in the Human Tissues Act (Act 65 of 1983) or any amendment thereto or replacement thereof;
6.1.5.23 If the consequences of an Accident shall be aggravated by any condition or physical disability of the Insured Person which existed before the Accident occurred, the amount of any compensation payable under this Insurance in respect of the consequences of the Accident shall be the amount which it is reasonably considered would have been payable if such consequences had not been so aggravated;
6.1.6 In addition to the above, qualified medical advice shall be sought and followed promptly on the occurrence of any Bodily Injury, Dread Disease or Illness and the Insurer shall not be liable for any part of any claim which in the opinion of the medical adviser arises from the unreasonable or wilful neglect or failure of an Insured Person to seek and remain under the care of a qualified member of the medical profession.
6.1.7 Unless specifically allowed for, compensation for the same trigger event or illness may not be claimed under more than one benefit. Examples include: Should the insured be diagnosed with a dread disease and is hospitalized later due to an illness that resulted directly from the dread disease, all benefits related to the same trigger event should be claimed under the one benefit.
6.1.8 Where an Insured Person is covered in terms of a statutory body such as the Compensation for Occupational Injuries and Diseases or the Road Accident Fund or their successors in title or assigns, in relation to an Accident, the Insurer will only be liable for amounts that the Insured may be liable for due to shortfalls incurred and up to the maximum Accident Benefit amount.
6.1.9 If your hospital illness benefit distinguished between tariffs for normal ward and ICU / High Care, the split of the tariffs will be based on the number of days you’ve been in hospital as from your originally admission date.
6.1.10 For example: if you have been in ICU for 3 days, day 1 to 3 will be calculated on ICU/High Care tariffs and your normal ward benefit will be calculated from day 4 tariffs onwards. If you were admitted the normal ward for 5 days and then transferred to ICU/High Care for another 5 days, your benefit will be calculated as follows: Day 1-5 based on normal ward tariffs and day 6-10 based on ICU/High Care tariffs. If you are transferred back to normal ward, the benefit will be calculated as from day 11 on normal ward tariffs. Limited to your annual over all limits.
6.1.11 With regards to an Illness:. A recurrence of any Illness will only be considered a separate Illness if 6 (six) months have elapsed from the date of onset of the preceding Illness and which has a definite diagnosis and treatment plan. 6.1.11.1 Kaposi’s Sarcoma; 6.1.11.2 Pneumocystis carinii;
5.7.2.3.3.3 polarisation. 5.7.2.4 Any enhancements will be for the member’s own account. 5.7.2.5 The waiting period for Optometry Top-up is six months. 5.7.3 Dentistry Top-up 5.7.3.1 Practices: Should there be no authorisation obtained where indicated in limitations, no benefit
will be paid. 5.7.3.2 The waiting period for Dentistry Top-up is three months. 5.7.3.3 List of dental procedures:
LIST OF DENTAL PROCEDURES – TOP-UP
Codes Description Left/right
Consultation
8101 Full mouth examination chart-ing and treatment plan
Twice per member per benefit year (180 days apart from previous 8101)
8104 Examination or consultation for a specific problem, not requiring charting and treatment planning
Not within four weeks of 8101, 8102 or 8104 (not covered if no clinical procedure is charged)
8107 Intra-oral radiographs per film Pre-authorisation and motivation required prior to claims submission when quantity is more than the following:• With 8101 – 2x8112 and 1x8107• With 8104 – 1x8112 or 8107• No consult – 1x8112 or 8107• Maximum quantity of seven per year
8112 Intra-oral radiographs per film
8109 Infection control Maximum of two per visit
8145 Local anaesthetic per visit Maximum of one per visit
Preventative Codes
8155 Polish (all ages) 8155 and 8159 – once per six months per member
8159 Scale and polish
8161 (8162)
Fluoride treatment Once every six months per member younger than 12 years
8110 Provision of heat or vapour sterilised and wrapped instru-mentation
Will only be paid if code 8731, 9013, 9011, 8201 or 8202 is claimed
8110 Provision of heat or vapour steril-ised and wrapped instrumentation
Will only be paid if code 8731, 9013, 9011, 8201 or 8202 is claimed
Extraction Codes
8201 Extraction – single tooth One per quadrant per member per visit
8202 Extraction – each additional tooth in the same quadrant
Four and more require pre-authorisation
Emergency Codes
8132 Pulp removal (emergency root canal treatment)
8132 cannot be claimed with 8131 or any restoration, root canal and extraction code. Maximum of one per beneficiary per annum
8131 Emergency treatment where no other treatment code is applicable
Cannot be claimed with 8132 and limited to one per benefi-ciary per annum
Restoration Codes
8341 (8367)
Amalgam – one surface Pre-authorisation and X-rays required for:• More than four restorations per year (especially anterior
teeth)• Two, three, four or more surface fillings per visit• More than two anterior restorations per visit• Multiple fillings on an anterior tooth on the same service date• Posterior teeth restorations cannot be performed across the
midline. Deviations will only be covered if pre-authorised• Any three or four surface fillings on wisdom teeth
General Rules:• Restoration code per tooth number in a nine-month period.
Will not be covered:• Repairing of teeth damaged due to bruxism, toothbrush abra-
sion, erosion and fluorosis• Replacement of non-carious amalgam with resin• Fillings on non-functional wisdom teeth
8342 (8368)
Amalgam – two surfaces
8343 (8369)
Amalgam – three surfaces
8344 (8370)
Amalgam – four or more surfaces
8351 Resin – one surface
8352 Resin – one surface
8353 Resin – one surface
8354 Resin – four surfaces
Surgical Incisions
8731 Incision and drainage of abscess – intra-oral
9011 Incision and drainage of abscess – intra-oral (pyogenic)
9013 Incision and drainage of abscess –intra-oral (pyogenic)
6 EMERGENCY HOSPITAL COVER*Emergency hospital cover not applicable to Primary Care Plan 6.1 General Exceptions 6.1.1 An Insured Person may not be covered for more than one Policy under this insurance category. 6.1.2 The Policyholder will not be entitled to any benefits if admission is required for the purposes
of investigative procedures or any other investigation only, unless specifically provided for in this agreement.
6.1.3 Any other surgical procedures where admission to a hospital or day clinic is less than 24 consecutive hours and which procedures are not specified under the Specific Illness Benefit and which is not related to an accident will be excluded.
6.1.4 This policy does not cover any admission to hospital which is a result or relate to complications or conditions arising as a result of pregnancy or during childbirth during the first 12 (twelve) months
6.1.11.3 Tuberculosis; 6.1.11.4 CMV; 6.1.11.5 Cryptococcal meningitis; 6.1.11.6 Cryptosporidium; 6.1.11.7 Disseminated Herpes / Shingles.
7 MATERNITY BENEFITS*Maternity cover not applicable to Primary Care Plan 61+*Maternity cover not applicable to Primary Care Plan 61+ 7.1 The waiting period for your maternity benefit is 12 months from membership commencement. 7.2 You’ll be required to make an upfront payment to the service provider and submit the claim to GetSavvi
Health for reimbursement. 7.3 Maternity benefits are limited to one of two birth procedures: 6.3.1 R20 000 cover for a normal birth; or 6.3.2 R30 000 cover for a C-Section. 7.4 Birth procedures include all costs in relation to birth from the initial gynaecologist visit up until birth at the
stated benefit values only. 7.5 Members are not limited to a network provider and may use any provider of their choice, provided that the
service provider is a registered gynaecologist. 7.6 Maternity benefits are only available to the main member or spouse and do not apply to dependants.
8 FEELBETTERFAST 8.1 One flu vaccination per member per year to be administered by 31 May each year. 8.2 One tetanus vaccination per member every 10 years. 8.4 The FeelBetterFast benefit may be used at any network pharmacy nationwide. Members may contact the
Call Centre on 0861 18 92 02 where a GetSavvi Health consultant will help the member find a network pharmacy closest to them.
8.5 This benefit is limited to 12 consultations per policy per annum with a registered nurse or pharmacist, and free prescribed medication according to a formulary.
9 NETCARE 911 EMERGENCY SERVICES 9.1 The benefit offers a 24-hour medical information hotline, 082 911, which includes the necessary
medical personnel such as paramedics, nurses and doctors, to provide general medical information and advice.
9.2 The scheme will not pay for transportation using a third party provider (unless arranged by Netcare). All emergency transportation requests must be made by dialling 082 911. Should Netcare not have an ambulance or other suitable vehicle available, they will arrange with a different vendor to act on their behalf.
10 PREVENTATIVE BENEFITS 10.1 One pap smear per female aged 21 or older every three years. 10.2 One pneumococcal (pneumonia) vaccination every five years for members aged 65 or older, or
individuals with a medically-proven compromised immune system. 10.3 One prostate-specific antigen screening per male member, aged 50 years and over, every two years. 10.4 One Hepatitis A and B vaccination per member during the lifetime of the policy. 10.5 See FeelBetterFast preventative benefits exclusions and limitations under point 6 above.
11 FUNERAL BENEFIT 11.1 Comprehensive Family Funeral Plan 11.1.1 Cover for all participants in terms of the Comprehensive Family Funeral Plan will stop on the day
that the principal member dies and the compulsory group scheme is canceled. 11.1.2 A waiting period for death due to suicide applies. Where a participant commits suicide, no benefit will be
paid if the suicide is committed within the first 12 months of the policy being entered into. 11.1.3 Pre-existing conditions: No benefit will be paid out should a participant die of a pre-existing
condition within the first 6 months that the policy is active. 11.1.4 No claim will be admitted in terms of this Policy if the event giving rise to the claim is caused directly
or indirectly by or is in any way attributable to any of the following: 11.1.5 The willing participation by the Principal Insured or such other insured persons under this Policy,
in any of the following: 11.1.5.1 an act of war (whether war is declared or not); 11.1.9.2 military action; 11.1.5.3 Riot or unlawful strike; 11.1.5.4 civil commotion; 11.1.5.5 usurpation of power; 11.1.5.6 martial law; 11.1.5.7 terrorism; and; 11.1.5.8 any usage of nuclear, chemical and biological weapons, device or agent. 11.1.5.9 A disease, epidemic or a pandemic; 11.1.5.10 An Act of Government; 11.1.6 Any act or deed by the Principal Insured deliberately committed in violation of any law as well as any
other insured person under the Policy including but not limited to a minor child, where his/her parent and/or legal guardian knowingly allows such child to participate in any act which constitutes a violation of any law;
11.1.7 Self-inflicted injury or self-inflicted illness, whether intended or not, or voluntary exposure to danger or obvious risk of injury. Any injury or disease which is caused partly by the actions or omissions of the insured, but in conjunction with the action or omission of some other party of some other contributory factor, will fall outside the ambit of the above exclusion;
11.1.8 Every time the benefit is increased in anyway, the waiting period will then again become applicable to the increased amount. If death due to suicide or a pre-existing condition occurs within this additional waiting period, then the participant may be paid out a benefit equal to the previous benefit level.
GENERAL TERMS AND CONDITIONS
These are the standard Terms and Conditions relating to your chosen plan. Please read them carefully, as by entering into a contract with the company you will be bound hereto.
1 DEFINITIONS AND INTERPRETATION 1.1 ‘Abuse’ means usage of benefits that exceeds the average, e.g., the average GP visits per year is 12 per
family. Therefore, abuse would be investigated once usage exceeds this value. 1.2 ‘Accident’ or ‘accidental injury’ means an unforeseen event which could not reasonably have been
expected to occur. 1.3 ‘Aids’ (Acquired Immune Deficiency Syndrome) and ‘HIV’ (human immunodeficiency virus) shall have
the meanings assigned to these terms by the World Health Organisation and shall include opportunistic infection, malignant neoplasm, encephalopathy (dementia), HIV wasting syndrome or any disease or illness in the presence of a seropositive test for HIV.
1.4 ‘Business day’ means any day that is not a Saturday, Sunday or South African public holiday.
1.5 ‘Commencement date’ means the first day of the month following the month in which the principal member’s application is accepted by the company (‘the contract’) and payment of the principal member’s first monthly premium is reflected in the company’s nominated bank account. For the sake of clarity and by way of an example, if the principal member’s application is accepted on 15 July and payment is reflected in the company’s bank account on 25 July, then the commencement date will be 1 August.
1.6 ‘Company’ means GetSavvi Health (Pty) Ltd, registration number: 2011/008277/07, VAT registration number: 4290258682, a registered financial services provider, registration number: FSP 44283.
1.7 ‘Comprehensive Family Funeral Plan’ forms part of the product and means the funeral policy underwritten by African Unity Life Ltd, a licenced life insurer and authorised Financial Services Provider, FSP No. 8447.
1.8 ‘Contract’ means these Terms and Conditions as accepted by the principal member in their application for registration and will bind the member and the company on the date of written acceptance of the principal member’s application by the company and in accordance with the provisions of clause 7.3.
1.9 ‘CPA’ means the Consumer Protection Act 68 of 2008 and can be accessed at http://www.info.gov.za/view/DownloadFileAction?id=99961
1.10 ‘Date of inception’ means the date calculated three months from the commencement date (exclusive of the commencement date).
1.11 ‘Day-to-day Benefits’ forms a part of the product and means the health insurance underwritten by African Unity Life.
1.12 ‘Dentistry Top-up’ forms part of the product and provides the member with unlimited dentistry benefits. 1.13 ‘Dependants’ means the legal spouse (by civil or traditional marriage) of the principal member and is
limited to one spouse (as stipulated by the member when entering into the contract) and any number of children of the principal member (be they natural, step, adopted or fostered).
1.14 ‘Eligible child’ means a child who is a natural or biological, step- or legally adopted child placed under the foster care of the principal member and who has not attained the age of 21 years. This age may be extended to 25 years in respect of an unmarried child who is a full-time student. There will be no age restriction for children who are either mentally or physically incapacitated from maintaining themselves, provided that the children are wholly dependent on the principal member for support and maintenance. In the event that the principal member requires extension of cover for children over 21 years, the member will need to provide motivation in writing along with supporting documentation for this request. The extension will only be considered if the children were covered prior to reaching 21 years of age.
1.15 ‘Eligible spouse’ means the legally married spouse of the principal member and specifically excludes a common law spouse, unless the common law marriage has been registered as a common-law marriage, and who shall be required to register prior to becoming eligible for benefits by following the registration procedure prescribed by the service provider or its agents in their sole discretion. Should the principal member have more than one spouse who could qualify as an eligible spouse, then that principal member must make an irrevocable nomination of one eligible spouse to whom the benefits provided in these Terms and Conditions are to apply. No benefits will be paid in respect of an eligible spouse if more than one person qualifies as such and no nomination has been made by the principal insured person.
1.16 ‘Emergency’ means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part or would place the person’s life in serious jeopardy.
1.17 ‘Emergency Hospital Cover’ forms part of the product and means hospital cover in an emergency in terms of the Emergency Casualty Benefit, Emergency Stabilisation Benefit and Personal Accident Benefit.
1.18 ‘Family’ means the principal insured person and such person’s eligible adult dependants (provided such adult is an insured person but not a principal insured person) and such person’s eligible children, provided they are insured persons. For members on the Primary Care Plan 61+, ‘family’ comprises the main member and spouse only; no other dependants.
1.19 ‘FeelBetterFast’ forms part of the product and refers to pharmacy visits for minor ailments as an alternative to GP visits.
1.20 ‘Discount Coupons’ forms part of the product and refers to monthly discount coupons for non-medical products at Shoprite, Checkers, CheckersHyper and Dis-Chem.
1.21 ‘GOP’ means guarantee of payment. The method through which the company guarantees the hospital payment for services rendered based on the diagnosis provided.
1.22 ‘Hospital’ means any institution in the Republic of South Africa (RSA) which, in the opinion of the service provider, meets each of the following criteria:
1.22.1 Has diagnostic and therapeutic facilities for surgical and medical diagnosis and treatment and care of sick persons under the supervision of a staff of registered medical practitioners;
1.22.2 Is not a hospice, place of rest for the aged, a place of rehabilitation of drug addicts or alcoholics, a health hydro, a homeopathic clinic or similar establishment;
1.22.3 Is not an institution providing long-term care of the blind, deaf, dumb or other handicapped persons; 1.22.4 Is not other than incidentally either a mental institution nor a convalescent home; and 1.22.5 Provides a nursing service supervised by registered nurses or nurses with equivalent qualifications. 1.23 ‘Hospital confinement’ means admission to a hospital ward limited to the general ward, high care ward
and special care units, including but not limited to an intensive care unit (ICU), excluding Private Hospital Benefits, as an inpatient where such admission is medically indicated and necessary.
1.24 ‘Illness’ means any one somatic illness or disease which manifests itself during the period of insurance and includes premature senile degenerative changes, but not an illness which is of such a nature as to be incapable of diagnosis by objective evidence or which, though capable of diagnosis by such evidence, has not been so diagnosed.
1.25 ‘Injury’ means a sudden and unexpected bodily injury necessitating Primary Healthcare Benefits and/or Emergency Medical Benefits.
1.26 ‘Insured event’ means any injury or illness which causes a principal member to undergo certain medical treatment and/or the necessity to be confined to hospital and undergo certain medical or surgical treatment.
1.27 ‘Insured incident’ means any one accident (as defined) or illness (as defined) and/or emergency (as defined) that necessitates an insured person to undergo certain medical treatment (as defined).
1.28 ‘Insured person’ means a principal insured person; an eligible spouse of a principal insured person; an eligible child of a principal insured person; or such other person as the service provider may from time to time deem eligible. (On the death of the principal insured person, the cover of the eligible spouse under this policy may be continued should such spouse elect to do so within 60 days of the death of the principal insured person.)
1.29 ‘Insurer’ means African Unity Life Ltd, registration number: 2003/016142/06. 1.30 ‘Long Term Insurance Act’ means the Long Term Insurance Act No. 52 of 1998. 1.31 ‘Maternity Benefits’ forms part of the product and provides the member with cover from pregnancy
up until birth. 1.32 ‘Medical emergency transportation’ means all transportation by ambulance to the most appropriate
hospital. 1.33 ‘Medical practitioner’ means a legally qualified registered medical practitioner. 1.34 ‘Medical tariff’ means the standard tariff as agreed to between the service provider and the network
general practitioner for payment of medical services. 1.35 ‘Member’ means the principal member and the member’s dependants.
1.36 ‘Membership file’ means a file kept by the company containing the principal member’s registration information. 1.37 ‘Month’ means a month in a given contract year. 1.38 ‘National Health Reference’ means the standard anatomical tariff system. 1.39 ‘Netcare 911 Emergency Services’ forms a part of the product and means the Netcare 911 Emergency
Services provided by Netcare. 1.40 ‘Optometry Top-up’ forms part of the product and provides the member with optometry benefits where
only one member on the plan has access at a time within a two-year period. 1.41 ‘Participant’ means the persons nominated by the principal member to be covered in terms of the
Comprehensive Family Funeral Plan and includes the principal member. 1.42 ‘Pre-authorisation service’ means a telephonic Call Centre service in terms of which the service provider
will pre-approve treatment for a principal member in terms of this contract. GetSavvi Health reserves the right to reject pre-authorisation requests.
1.43 ‘Premium’ means the monthly premium payable by the principal member to the company in advance on the irrevocable date specified in the principal member’s registration information, being the date upon which the principal member’s salary is due to be paid and due on the same date every month by way of direct debit order or such other means as the company may direct in writing until such time as the contract is cancelled by either the member or the company or both in accordance with the provisions of these Terms and Conditions.
1.44 ‘Principal insured person’ or ‘Principal member’ means the person who enters into a contract with the service provider and is accepted by the service provider as eligible for participation in the insurance provided by this policy.
1.45 ‘Product’ means your chosen plan, either the: 1.45.1 Get Care Plan, encompassing Emergency Hospital Cover; Maternity Benefits; FeelBetterFast;
Netcare 911 Emergency Services; Member Wellness Programme; Unlimited HIV, Trauma and Assault Counselling; Preventative Benefits; 24-hour Health Advisor; Discount Coupons; and Comprehensive Family Funeral Plan.
1.45.2 Primary Care Plan, encompassing Day-to-day Benefits; Maternity Benefits; FeelBetterFast; Netcare 911 Emergency Services; Member Wellness Programme; Unlimited HIV, Trauma and Assault Counselling; Preventative Benefits; 24-hour Health Advisor; Discount Coupons; and Comprehensive Family Funeral Plan;
1.45.3 Primary Care Plan +, encompassing Day-to-day Benefits; Emergency Hospital Cover; Maternity Benefits; FeelBetterFast; Netcare 911 Emergency Services; Member Wellness Programme; Unlimited HIV, Trauma and Assault Counselling; Preventative Benefits; 24-hour Health Advisor; Discount Coupons; and Comprehensive Family Funeral Plan;
1.45.4 Primary Care Plan Top-up, encompassing Day-to-day Benefits; Maternity Benefits; FeelBetterFast; Netcare 911 Emergency Services; Member Wellness Programme; Unlimited HIV, Trauma and Assault Counselling; Optometry and Dentistry Top-up; Preventative Benefits; 24-hour Health Advisor; Discount Coupons; and Comprehensive Family Funeral Plan;
1.45.5 Primary Care Plan + Top-up, encompassing Day-to-day Benefits; Emergency Hospital Cover; Maternity Benefits; FeelBetterFast; Netcare 911 Emergency Services; Member Wellness Programme; Unlimited HIV, Trauma and Assault Counselling; Optometry and Dentistry Top-up; Preventative Benefits; 24-hour Health Advisor; Discount Coupons; and Comprehensive Family Funeral Plan; or
1.45.6 Primary Care Plan 61+, encompassing Day-to-day Benefits; Emergency Hospital Cover; FeelBetterFast; Netcare 911 Emergency Services; Member Wellness Programme; Unlimited HIV, Trauma and Assault Counselling; Preventative Benefits; 24-hour Health Advisor; Discount Coupons and Comprehensive Family Funeral Plan.
1.46 ‘Recommended scale of benefit’ means the standard tariff as a guideline for payment of medical services. 1.47 ‘Registration information’ means the member’s name, telephone number, email and physical addresses,
salary payment date and any other personal information requested by the company. 1.48 ‘Schedule’ means the schedule attached to and forming part of this policy. 1.49 ‘Service provider’ means GetSavvi Health (Pty) Ltd, registration number: 2011/008277/07, VAT registration
number: 4290258682, a registered financial services provider, registration number: FSP 44283. 1.50 ‘Service providers’ means the third parties who are contracted by the company to provide the product to
the member and are as follows: 1.50.1 Day-to-day Benefits: African Unity Life (www.africanunity.co.za) 1.50.2 Maternity Benefits: African Unity Life (www.africanunity.co.za) 1.50.3 Emergency Hospital Cover: African Unity Life (www.africanunity.co.za) . 1.50.4 Netcare 911 Emergency Services: Netcare 911 (www.netcare911.co.za) 1.50.5 Member Wellness Programme: LifeAssist (https://yourlifeassist.co.za) 1.50.6 Unlimited HIV, Trauma and Assault Counselling: LifeSense Group (Pty) Ltd (www.p3protector.co.za) 1.50.7 Comprehensive Family Funeral Plan: African Unity Life (www.africanunity.co.za) 1.50.8 24-hour Health Advisor: Netcare 911 (www.netcare911.co.za) 1.50.9 FeelBetterFast: Health Craft (www.healthcraft.co.za) 1.50.10 Discount Coupons: African Unity Life (www.africanunity.co.za) 1.51 ‘Treatment’ means any form of investigation or examination by, consultation with or a surgical procedure
performed by a medical practitioner (as defined) for the purpose of treating or monitoring an insured person’s medical condition arising out of an insured incident.
1.52 ‘24-hour Health Advisor’ forms a part of the product and provides the member with telephonic health advice 24 hours a day, seven days a week.
1.53 ‘‘Member Wellness Programme’ forms part of the product and provides professional and confidential counselling, support, awareness and advice on a range of topics.
1.54 ‘Unlimited HIV, Trauma and Assault Counselling’ forms part of the product and provides the member with telephonic advice as covered by the HIV Assistance Programme and Trauma Assistance Programme 24 hours a day, seven days a week.
1.55 ‘Website’ means www.getsavvi.co.za 1.56 If any provision in a definition is a substantive provision conferring rights or imposing obligations on the
parties hereto, effect shall be given to it as if it were a substantive clause in the body of the contract, notwithstanding that it is only contained in this clause 1.
2 IMPORTANT NOTICES 2.1 This document contains the standard Terms and Conditions of the product in terms of the contract
(‘Terms and Conditions’). 2.2 These Terms and Conditions will be binding between the parties for all current and future products unless
otherwise notified to the member by the company in writing. 2.3 Nothing in these Terms and Conditions is intended to, nor must be understood to, unlawfully restrict, limit
or avoid any rights or obligations, as the case may be, created for either the member or the company in terms of the provisions of the CPA.
3 INTRODUCTION 3.1 The Company is GetSavvi Health (Pty) Ltd, registration number: 2011/008277/07, VAT registration number:
4290258682 and is in the business of offering the product to its members and located on the 4th Floor, Tygervalley
Chambers 5, 27 Willie Van Schoor Avenue, Tygervalley, BELLVILLE, 7530, WESTERN CAPE, SOUTH AFRICA. 3.2 The company’s directors are Gustav Terblanche and Wayne Moosa (CEO). 3.3 GetSavvi Health (Pty) Ltd is an authorised financial services provider, FSP Number: 44283, and complies
with the long-term insurance acts of South Africa. 3.4 A representative of the company can be contacted at 0861 18 92 02 or [email protected].
4 AGREEMENT 4.1 These Terms and Conditions form the entire agreement between the company and the member, save that
the member shall, in addition hereto, be bound to the website’s Terms of Use, Funeral Policy Document and the service providers’ Terms and Conditions for the Health Insurance and Netcare 911 Emergency Services. No other Terms and Conditions, whether express, tacit or implied will apply, irrespective of the circumstances under which the contract arose.
4.2 These Terms and Conditions may be periodically modified and/or amended by the company at any time and in their sole discretion, a copy of which will be made available by the company to the principal member as the company may deem appropriate, and it is the member’s responsibility to ensure that they are familiar with the updated or amended terms. The member’s continued payment for and use of the product in any way whatsoever signifies the member’s acceptance of the Terms and Conditions and any updates and/or amendments thereof.
5 REGISTRATION 5.1 The principal member will be required to submit an application and complete their registered information
in such registration application to be submitted to the company. The company reserves the right to accept or reject any application by the member to enter into a contract with the company.
5.2 The physical home and email addresses provided by the principal member to the company will be the member’s domicilium citandi et executandi for the purposes of serving all documentation, including legal process on the member.
5.3 The member warrants that all registration information provided by the principal member (or by an authorised representative) to the company is true, accurate and complete. Neither the company nor the service providers are under any obligation to verify the member’s registration information nor will they be responsible for any errors relating thereto.
5.4 The member will be solely and exclusively responsible for maintaining the confidentiality of the registration information.
6 PAYMENT OF PREMIUMS 6.1 Premiums are payable by the principal member to the company in advance on the irrevocable date
specified in the principal member’s registration information, being the date upon which the principal member’s salary is due to be paid and due on the same date every month by way of direct debit order or such other means as the company may direct in writing.
6.2 The principal insured person will bear the cost of the premiums required to provide the benefits under the policy and will pay the premiums and any charges due to the service provider. The amount of premiums payable to secure the benefits will be calculated by the service provider in accordance with the scale of premium rates in force at the date of calculation.
6.3 The benefits of the contract will come into force on the first day of the month following the month in which the principal member’s application is accepted by the company (‘the contract’) and payment of the principal member’s first monthly premium is reflected in the company’s nominated bank account. For the sake of clarity and by way of an example, if the principal member’s application is accepted on 15 July 2016 and payment is reflected in the company’s bank account on 25 July 2016, then the commencement date will be 1 August 2016.
6.4 If the principal member, for any reason whatsoever, fails to make payment of any premium on the due date or the direct debit order is returned unpaid for any reason, then the company will double debit the member’s nominated account in the following month. If, in the second month, the debit order is returned unpaid or if the member fails to make payment to the company, as per Rule 15 A of the Policyholder Protection Rules, then the contract will be deemed to be canceled. The product and the benefits accruing in terms thereof will be suspended for the period that the premiums remain unpaid, i.e., the month that the premiums are not paid. If the member wishes to reinstate the product after the first day of the second month as aforementioned, then the member will enter into a new contract at the sole discretion of the company, subject to a three-month waiting period before the member will have access to and receive benefits from the product. The member will be required to make payment of the premium during this three-month waiting period.
6.5 No latitude, extension of time or other indulgence which may be given or allowed, whether by agreement or inadvertently by the service provider in respect of the performance of any obligation in terms of this contract, will under any circumstances be construed to be implied consent or operate as a waiver or a novation of, or otherwise affect any of the rights of the service provider or stop the service provider from enforcing, at any time and without notice, strict and punctual compliance with each and every obligation of the participating group.
6.6 If premiums, in whole or in part, are in arrears, then no claim will be payable until all the arrears have been settled in full. Once the arrears have been settled in full, the benefits will be available from the first of the following month.
6.7 The company reserves the right to increase the premium from time to time to reflect changes in claims experience and increases in medical inflation. The company will provide the principal member with one month’s prior written notice of such increase coming into effect.
6.8 All premiums and benefits due to or payable by the service provider will be paid in the lawful currency of the RSA.
7 JURISDICTION 7.1 The policy will be subject to the laws of the RSA whose courts will have sole jurisdiction to the exclusion of
the courts of any other country. 7.2 Where payment is to be made to or by the service provider, the currency will be that of the RSA at the
service provider’s head office unless the service provider allows otherwise.
8 COMMENCEMENT OF COVER 8.1 The date specified in the Policy Schedule, specifying the Commencement Date of this policy.
9 AMENDMENTS 9.1 The service provider reserves the right to adjust the premiums by giving 31 days’ written notice to the
principal insured person.
10 SERVICE PROVIDERS 10.1 The company has engaged the services of reputable service providers. However, the company cannot
guarantee the quality of service provided by these service providers to the member at any time. 10.2 The relationship between the company and the service providers is mutually exclusive and will not be
construed as being a relationship of principal and agent, a joint venture, partners, co-partners, employer and employee or any other similar relationship, the existence of which is hereby expressly denied.
11 MEMBERSHIP PACK AND CARD(S)
11.1 A membership pack will be sent electronically within the month of commencement of the policy The electronic pack will contain the membership certificate, electronic membership card and policy document. Should you, as a member, require a physical card, you may request it through our Call Centre (0861 18 92 02).
11.2 An electronic membership card will be issued to the principal member and spouse (where applicable). A replacement electronic membership card will be issued on request from the principal member. Should a physical or replacement membership card be required, a once-off fee of R50 per card will be charged.
11.3 Updated electronic membership card(s) for additional dependants will only be available. In the case where more than five dependants are included on the policy, a secondary electronic card(s) will be issued detailing the additional dependants with dependant codes.
11.4 The membership card(s) must be presented when visiting any of the service providers on the network at any of the prescribed consultations.
12 CANCELLATION OF THE CONTRACT 12.1 The principal member may cancel the contract at any time subject to the following: 12.1.1 Entering into the contract is subject to a 31 day cooling-off period. Should the member wish to
exercise his/her right to cancel the contract within the above-mentioned period, then the member must inform the company in writing. Notice as aforementioned will only be deemed to be effective once physically received by the company, and the obligation is on the member to ensure that the notice is received thereby. The 31-day aforementioned period is calculated from the date that the policy was sold to the member.
12.1.2 If the member wishes to cancel the contract after the aforementioned 31-day period, then the contract will continue until the end of the month in which the prior written notice is given and the member will not be entitled to a refund.
12.1.3 Cancellation of any of the individual products within the product range immediately cancels the product and the contract entered into between the company and the member.
13 TERMINATION OF COVER 13.1 The service provider, giving 31 days’ notice in writing, may cancel this policy at any time. 13.2 The principal insured person may cancel this policy at any time by giving 31 days’ notice in writing. 13.3 An incident will only qualify if the treatment caused by such incident commences before the date of
cancellation, in which case all outstanding claims must be submitted to the service provider within three months after the date of cancellation.
14 LIMITATION AND INDEMNITY 14.1 In addition to any other exclusion contained herein, the parties agree that the member and/or participant
shall have no claim whatsoever against the company, its employees, directors and/or agents for any loss or damages of any nature, including but not limited to, consequential damages arising out of advice dispensed or information given, save where otherwise contemplated in the CPA, provided that nothing in these Terms and Conditions must be construed in any way as limiting the rights of the company to raise such defences as may be available to it at common law or in terms of statute.
14.2 Save as otherwise provided in the CPA (where applicable), the member hereby indemnifies and holds the company, its employees, directors and/or agents harmless for any losses (including the loss of life), expenses, costs or damages of whatsoever nature incurred by the member and/or his/her participants arising from the misconduct or negligence of the company, its employees, directors and/or agents.
15 FORCE MAJEURE 15.1 Neither party shall take responsibility nor liability with respect to any failure or delay in performance
of their obligations under the contract and these Terms and Conditions if such failure or delay in performance is due to any cause beyond their control, including but not limited to, acts of God, flood, fire, strike, industrial unrest, acts of war, insurrection, riot or civil disorder, natural calamities, pandemics or any other decree, law or regulation of a court of law. Proof of force majeure may be requested to be furnished by one party to the other.
16 MISCELLANEOUS 16.1 All referrals made by the company and/or service providers to the member shall be for the member’s
sole account. For the sake of clarity and by way of an example, if the member is referred to the hospital by a medical advisor, then all and any costs associated therewith, including, without limitation, transport to and from the hospital, shall be for the sole and exclusive account of the member. The company shall similarly not be liable for any legal, medical or other fees incurred, directly or indirectly, by the member.
16.2 The company considers that the convenience of the member having products bundled outweighs the limitation of the member’s right of choice and can show that the bundling of the products results in an economic benefit for the member.
17 LEGAL 17.1 The member may not actually nor purportedly cede, assign or otherwise alienate any rights or obligations
which he/she may have in terms hereof or in terms of any contract with the company without the company’s prior written consent.
17.2 Each provision of these Terms and Conditions is, notwithstanding the grammatical relationship between that provision and the other provision of these terms and conditions, severable from the other provisions of these terms and conditions. Any provision of these Terms and Conditions that is or becomes invalid, unenforceable or unlawful in any jurisdiction shall, in such jurisdiction only, be treated as though it had never been written to the extent that it is so invalid, unenforceable or unlawful without invalidating or affecting the remaining provisions of these terms and conditions which shall remain in full force and effect. The company declares that it is their intention that these Terms and Conditions would be executed without such invalid, unenforceable or unlawful provision if they were aware of such invalidity, unenforceability or unlawfulness at the time of the contract coming into force
17.3 No latitude, extension of time nor other indulgence which may be given or allowed, whether by agreement or inadvertently by the company to the member in respect of performance of any obligation in terms of these Terms and Conditions shall, under no circumstances, be construed to be implied consent or operate as a waiver or novation of or otherwise affect any of the rights of the company or stop the company from enforcing, at any time and without notice, strict and punctual compliance with each and every obligation of the company.
17.4 These Terms and Conditions and the contract will be governed by and interpreted in accordance with the laws of the Republic of South Africa.
17.5 In terms of Section 45 of the Magistrates Court Act of 1944, as amended, the member hereby consents
to the jurisdiction of the Magistrates Court having jurisdiction in terms of Section 28 of said Act in respect of any action to be instituted against the member by the company in terms of the contract or this document. It shall nevertheless be entirely to the discretion of the company as to whether to proceed against the member in such Magistrates Court or any other court having jurisdiction within the Republic of South Africa.
17.6 In the event of the member committing a breach of the contract or in the event of the company being required to take legal action against the member for any reason whatsoever, the member agrees and undertakes to pay the company’s legal costs on the High Court tariff scale, including collection commission, tracing fees and other expenses connected therewith.