SPECIALISED RISK SOLUTIONS

Technical Guide 2016

Contents

1. Xelus - Structure & Background ________________________________________ 1

2. Fusion & FusionX - Overview & Benefits ______________________________ 2 - 5

3. Terms & Conditions __________________________________________________ 6

4. Waiting Periods and Underwriting ____________________________________ 7 - 8

5. Exclusions __________________________________________________________ 8

6. Premiums - 2016 ____________________________________________________ 9

7. Quotations _________________________________________________________ 10

8. Application Procedure _______________________________________________ 10

9. Claim Procedure ____________________________________________________ 11

10. Contact Details _____________________________________________________ 12

11. Waiting Period Overview _____________________________________________ 13

SPECIALISED RISK SOLUTIONS

1. Structure & Background

Below is an organogram of stakeholders in the Xelus value chain:

Xelus is registered with the Financial Services Board as an

underwriting manager (‘UMA’) and we distribute our

products exclusively via independent intermediaries.

We have invested in our staff and systems to ensure

efficient and prompt service levels. All administrative

functions are undertaken by Xelus (i.e. premiums, claims,

queries, etc.)

In terms of a binder agreement, governed by the Binder

Regulations of the Short Term Insurance Act, Centriq fully

underwrites all our insurance products.

In their 2014 financial year, Centriq achieved a turnover in

excess of R2 billion, held reserves of nearly double the

statutory level required by law and in 2015 was upgraded

to a very secure AA- rating by Global Credit Ratings.

Centriq is also a wholly owned subsidiary of Santam, the

largest short term insurance company in South Africa.

Santam is the only short term insurer in the country that

carries the highest credit rating possible (AAA) from

Global Credit Ratings.

Intermediary

Clients

Binder HolderInsurance

Agreement

ClientAppointment

IntermediaryContract

100%Owned

1

2. Fusion

Xelus provides a single solution for the gap cover market, namely Fusion. The rationale behind this is simple yet highly

effective.

Fusion is specifically designed to provide an optimal gap cover solution

regardless of medical scheme or benefit option.

Fusion members never need to make an option choice, since they are

comprehensively covered for all in-hospital and oncology related shortfall

types.

This also removes FAIS liability from intermediaries relating to the advice

process since there cannot be an alternative product selection.

This singular approach is also easier to communicate to members and

engenders a level of confidence in clients.

Core Benefits

The core benefits are split into 2 areas of cover as shown

below - In-Hospital and Out-of-Hospital cover.

Core Benefits

In-Hospital

Tariff Shortfalls 500% of Scheme Tariff

Co-Payments & Deductibles Unlimited

Shortfalls from Sub-Limits R36,000 per event/condition

Out-of-Hospital

Oncology Co-Payments 20% (R300,000 pb per treatment cycle)

Oncology Sub-Limits 100% (R200,000 pbpa)

Co-Payments for MRI | CT | PET scans Unlimited

2

Tariff Shortfalls 500% for Scopes | Wisdoms | Oncologist | Dialysis | Home Births

Accidental Casualty R8,000 / event

The following provides an explanation on each category

of cover:

In-Hospital Cover

The following in-patient shortfalls are covered:

Tariff Shortfalls - are covered up to a maximum of 500% of

the medical scheme tariff. All services delivered while

in-hospital are covered, such as surgeons, anaesthetists,

physiotherapists, radiology, pathology, CT/MRI scans,

etc, etc.

There is no limit on this benefit.

Co-payments & Deductibles – Any fixed value

co-payment or deductible that is applied against

scheme benefits is covered. This benefit is payable

regardless of whether the co-payment or deductible was

paid from a medical savings account.

There is no limit on this benefit.

Penalty Co-payment/Deductible – Any fixed value

penalty co-payment or deductible that is applied

against the scheme benefits for the voluntary use of a

hospital or day clinic that is not a designated service

provider. This benefit is payable regardless of whether the

co-payment or deductible was paid from a medical

savings account.

This benefit is limited to 1 event per family per annum. No

rand limit applies.

Annual Sub-limits – shortfalls arising from the application of

an annual sub-limit for a specific medical category of

service will be covered (eg prosthesis for joint replacement,

MRI/CT scans, etc, etc). Cover does not apply where a

scheme has not approved a benefit – only where a

sub-limit, as registered in the medical scheme rules, applies

to the cover.

This benefit is limited to a maximum of R36,000 per event

or condition. No annual limit applies.

Out-of-Hospital Cover

The following out-patient shortfalls are covered:

Oncology Co-Payments – Co-payments that are

applied by a medical scheme once oncology costs

reach a pre-defined threshold are covered up to a

maximum of 20%, subject to a limit of R300, 000 per

beneficiary per treatment cycle.

This applies to all costs including biological drugs. No

formulary of biological drug types is applied and all types

of cancer are covered.

Oncology Sub-Limits – Where a medical scheme

applies an overall sub limit to oncology benefits, Fusion

will provide additional cover once such limited scheme

benefit is exhausted, up to a maximum of R200, 000 per

beneficiary per annum.

Cover does not apply where a scheme has not

approved a benefit or does not have a benefit – only

where a sub-limit, as registered in the medical scheme

rules, applies to the cover.

This benefit applies to biological drugs in accordance with

the following formulary: Alimta, Avastin, Erbitux, Faslodex,

Fludara, Gleevec, Herceptin, Mabthera, Mylotarg,

Nexavar, Sprycel, Sutent, Tarceva, Velcade & Zevalin

Tariff Shortfalls – Tariff shortfalls arising on the following

out-patient treatment will also be covered up to a

maximum of 500% of the scheme tariff:

Endoscopes – Any form of endoscopic procedure

performed out-of-hospital that would otherwise, if

performed in-hospital, attract a co-payment or

deductible from the medical scheme.

Dental extractions - Any form of surgical dental

extraction performed out-of-hospital that would

otherwise, if performed in-hospital, attract a co-

payment or deductible from the medical scheme.

Oncology – this relates to the fees of the oncologist and

is in addition to the oncology cover above.

Dialysis – this relates to the fees of a haematologist.

Home birth – this relates to the fees for a medical

practitioner, nurse or mid-wife for a non-hospital birth.

Accidental Casualty Cover – The cost of all treatment

provided at an out-patient casualty ward for injuries

resulting from accidental harm is covered. All related

services are covered, eg specialists, medication, radiolo-

gy, MRI/CT scans, etc. This benefit is payable regardless

of whether the treatment costs are paid from a medical

savings account.

This is subject to a limit of R8,000 per event or condition.

No annual limit applies.

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Family Booster

Birth 42 days or more before due date R12,000 per event

Hospital Booster

Daily lump sum from Day 7 to 13 R600 / day

Daily lump sum from Day 14 to 20 R1,200 / day

Daily lump sum from Day 21 to 30 R1,800 / day

1st Tier Hospital Booster Benefi ts are paid from day 1 to 13 for Trauma admissions & Family Booster claims

Family Protector

Death or Permanent Disability (Illness Related) R12,000 per beneficiary

Death or Permanent Disability (Accidental) R24,000 per beneficiary

Dental Reconstruction Benefit

For Oncology Treatment or Trauma up to R36,000 per event/condition

Medical Scheme Contribution Waiver

Death or Permanent Disability 6 Months (max R3,600 pm)

Gap Cover Premium Waiver

Death or Permanent Disability 6 Months (total premium)

Road Accident Fund Claims

End to end legal assistance in RAF Claim 100% RAF Benefit Allocation to Claimant

Benefit Extender

The Benefit Extender is automatically included within

Fusion so does not require any benefit choice or

additional premium.

The Benefit Extender provides financial protection in

circumstances where indirect medical costs are

incurred as a result of the major medical events listed

below:

Important Notes

• The Family Booster triggers a benefit on a per event

basis. As an example, if twins are born in the 32nd

week, then only one benefit payment of R12,000 will

be made. The same principle applies to the Hospital

Booster

.

• The Dental Reconstruction Booster will pay out up to

R36,000 per event or condition. It applies to

reconstruction necessitated by oncology treatment

and/or a trauma (eg car accident) that occurs after

commencement of the policy.

• The Contribution Waivers are payable upon death or

permanent disability of the principal member.

Benefi t Extender

4

FusionX combines the Fusion benefits with the AskNelson EAP services at a reduced rate for corporate clients.

FusionX is only available on a compulsory basis to employer groups of 20 or more members.

Family Support for Dependants

Counselling:Telephonic

(24/7/365) and face-to-face

R

FinancialSupport

Managerial Support and

Coaching

Marketing and Health Education

Online Health Portal

TraumaSupport

LegalAdvice

24-HourHealth Line

24h

Fusion Benefits

Life is full of personal challenges and inter-personal

problems that affect us all in some way. If we aren’t

proactive in dealing with these issues, they can take

their toll on our concentration, our work output, our

productivity and our motivation.

Common challenges people face today include things

like relationship problems, parenting concerns, personal

safety, financial worries, stress, illness, depression and

addictions.

Within the workplace, troubled employees can be a

costly risk, especially if they are often absent, negligent

or lacking focus. It’s estimated that absenteeism costs

South African companies up to R20 billion every year.

Presenteeism, which is the term used for employees who

are at work but who are not productive, is a related risk

that also erodes efficiency and drains bottom line

profitability.

Welcome to a New World of Wellness...

A Proven Solution in Times of Trouble...

The Ask Nelson Employee Assistance Programme (EAP)

is a reliable, proactive intervention that helps

companies enhance employee health and well-being

resulting in improved engagement and performance.

AskNelson supports employees and their families

proactively, enabling them to cope with personal

challenges and equipping them with valuable life skills.

Employees enjoy greater health and happiness with the

support of AskNelson, also reducing absenteeism,

boosting workplace morale and improving productivity.

FusionX ensures that employees have comprehensive

cover for both physical and mental wellness.

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3. Terms and Conditions

The following Terms & Conditions are applicable to

Fusion:

• Maximum entry age is

- 60 for individuals and groups of less than 20

- 65 for groups 20+ members

• Waiting periods may apply - this will be indicated on

the member’s policy schedule (see section 4 for an

explanation of when these will apply).

• Cover only applies to the member, spouse &

children (up to 26).

• Families that are covered on two medical schemes

can be covered together under one Fusion policy.

Adequate proof of the family relationship will be

required when submitting a claim.

• A spouse dependant on the medical scheme can

be the Xelus principal member.

The following waiting periods are applicable:

General Waiting Periods

• 3 months on all benefits

• 12 months on pre-existing conditions

• 12 months on maternity

Some or all of these may be waived (See section 4 for

full details of when and how waiting periods are

applied).

Important Notes

1. The 3 month general waiting period does not apply

to claims arising from accidental harm (i.e. trauma)

2. Waiting periods apply to all claims related to the

condition or event eg the maternity waiting period

will apply to all claims relating to maternity for the

mother and all claims for the new born infant from

the time of birth until the waiting period has expired

3. Waiting periods are applied at member level

depending upon the member's disclosure of

pre-existing medical conditions at the time of

application for cover (see section 4).

We will, therefore, inspect for any possible

non-disclosure of pre-existing medical conditions on

any member who claims within the first 12 months of

their membership.

This will not apply to employer groups of members

who are given proof-free acceptance of cover at

the time of application, eg compulsory groups of 20

or more (See section 4 for full details of when and

how waiting periods are applied).

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4. Waiting Periods & Underwriting

The following waiting periods and underwriting

procedures are applicable to new and existing groups.

4.1 Proof-FreeGroups (No Medical Underwriting)

Waiting periods are applied as per the following

criteria:

4.1.1 Compulsory Groups

If prospective groups of 20 or more join Xelus,

waiting periods will be waived for the group. This

waiver will also apply to new future members of

this group after the group has commenced

cover with Xelus.

The compulsory criteria must be confirmed on

the Xelus employer application form. This could

be for all medical aid members or possibly or all

medical aid members except those on network

options.

For compulsory groups of less than 20 members,

waiting periods will apply under the same rules as

per section 4.1.2 below.

4.1.2 Voluntary Groups with other gap providers

If existing prospective groups of 20 or more

switch cover from another gap provider to Xelus,

the waiting periods for the switching members

will be waived. All existing gap cover members

are required to switch unless otherwise agreed

upon in writing with Xelus.

This waiver does not apply to future employees

of such groups, i.e. after the initial group has

transferred to Xelus, the same waiting period

rules will apply for them as below for existing

voluntary groups.

For any voluntary group where new members

join the group under the following conditions:

• Within 2 months of commencing

employment at the group, or

• During a window period provided by Xelus to

that group,

Then the individual application form requires a single

medically related question to be answered by the

applicant.

In the event that the question is answered “No”, then all

waiting periods will be waived for that particular

member. Below is an excerpt of the relevant section of

the application form:

In answering the question below, consider any

dental treatment, family planning, consultations

with medical specialists, existing ailments and/ or

prescribed chronic medicine.

Qu: Are you or any of your dependants currently

aware of any reason that you or any of your

dependants may require hospitalisation or

cancer treatment within the next 12 months?

........... Yes / No

Answering “No” to the question above will result

in all waiting periods being waived. Please note

that any non-disclosure or misrepresentation

above may result in the policy being cancelled

or voided from inception.

In the event that the member answers “Yes”, then all

the standard waiting periods will apply.

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4.2 Medical Underwriting

1 Basic dentistry, as defi ned in the policy document, is covered.

Medical underwriting indicates that we will individually

assess the health status of the applicant and may

impose permanent exclusions or possibly decline the

application.

Medical underwriting will occur for the following

applicants:

• Private individuals, or

• to a group of less than 20 members,

or

• Any member joining any group more than 2

months after their date of employment (unless a

window period is provided for the group).

The medical questionnaire completed on the

application form will be taken into account for

Medical Underwriting purposes.

Condition specific exclusions may be applied

(members will be asked to sign acceptance of any

such exclusions).

Please note that as a short term insurer we are allowed

to refuse cover to a member or permanently exclude

a specific condition from cover.

5. Exclusions

A full list of the exclusions is contained within Section D of

the Fusion policy document. The pertinent areas that

are worth noting here are:

• Claims for day-to-day medical services (except

those specified in Section 2).

• Treatment for obesity which will include bariatric

surgery (aka stomach stapling).

• Treatment for cosmetic surgery is excluded unless

necessitated by a trauma or as a result of oncology

treatment (eg breast reconstruction following a

mastectomy).

• Any co-payment or deductible that is not a defined

rand amount (i.e. it is applied as a percentage).

Please note that this excludes the oncology co-

payment cover.

• Any penalty co-payment, deductible or limit

applied by a medical scheme for non-adherence

to the benefit rules or authorisation procedures (eg

non-authorisation of a hospital admission). Please

note that this exclusion does not apply where the

member is covered on a network hospital plan and

voluntarily makes use of a non-network hospital

facility).

• All specialised dentistry (excludes basic dentistry). 1

• Claims older than 4 months.

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6. Premiums - 2016

Premiums are established as follows for groups and

individuals.

Premiums for Groups of 20 or more

Xelus risk rates each prospective client group in

accordance with demographic composition and

medical scheme benefit option mix. It is, therefore, a

requirement to obtain a quote for each prospective corporate client in order determine the premium for the

group.

Membership data will be required for this purpose

(please see section 7 for the data requirements).

The premiums for future members of existing groups will

be the same as the group’s premium.

Each employer group’s premiums are revised annually

based upon the claims experience of the group and

the expected medical inflation for the coming year.

Premiums for Individuals andGroups < 20

The standard premium for individuals and groups of less

than 20 members is R196 effective as from 01 January

2016.

Members continuing with cover in their private capacity

after resigning from an employer group automatically

revert to the standard individual rate (R196). Only the

balance of waiting periods will apply in such instances

and a new policy number and schedule is issued.

9

We will require the following information in order to provide a comprehensive group quote:

Number of Dependants

Application Forms

Spouse Adult Children Benefit Option DOB, Age or ID No

7. Quotations

Based on the information a quotation will be provided

with the specific terms and conditions outlined on page

3 of the quotation.

Groups smaller than 20 members will not be quoted for

– the standard individual rate of R196 will automatically

apply and medical underwriting will apply.

8. Application Procedure

An Employer Application Form must be completed for

groups.

Note that premium collections for groups can be done

in one of the following 2 manners:

i. EFT Payment by employer (i.e. payroll deductions by

the employer)

ii. Individual debit order deductions against each

member’s personal bank account.

Xelus requires each applicant to complete an individual

application form (online or PDF e-Form) where the

employer is not fully subsidising the insurance premium.

For private members, no employer application needs to

be completed.

Once Xelus receives the individual application forms,

members will be loaded on the system and policy

documents will be sent via e-mail to each member. An

sms is also issued to the member notifying them of the

e-mail.

We can load a 2nd e-mail address on our system so that

intermediaries are copied when these policy

documents are issued.

This must be requested for each client group by the

intermediary.

Billing statements are issued to all groups on the 16th of

each month. Premiums are due by the 7th of each

month. (This excludes debit order clients.)

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9. Claim Procedure

A claim form can be downloaded from our website -

www.xelus.co.za

There is an option for members to sign an authority for

Xelus to obtain the relevant claims information on their

behalf.

For Discovery and Momentum - members must also sign

the relevant authority form from their medical scheme

(these are available from our office or click on the

relative weblink at the base of our claim form).

In so doing, we will be able to obtain the outstanding

supporting documentation on their behalf.

If members do not sign the authority form, the following

supporting documents are required:

1. Claims Transaction Remmittance from the Medical

Scheme;

2. Relevant Doctors Accounts;

3. Hospital Account (first 1-4 pages showing admission/

discharge times and ICD codes);

4 Current Medical Scheme Membership Certificate

(copy of the membership card is not accepted);

5. Proof of Date of Employment (copy of the top

section of payslip or a letter from employer).

This is not required for private individuals.

Claims are processed continuously as and when

received by Xelus and payments are made on a daily

basis.

An e-mail and sms notification are issued to the member

when:

• The claim is 1st captured;

• Requesting outstanding documentation (assuming

they have not signed the authority form);

• Authorising the claim payment.

NB: EFT payments can only be made to the principal member – by law we may not pay service providers.

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10. Contact Details

Marketing / Presentations / Quotes/ Training:Please note that as from 01 July 2015 all client services

and new business distribution services for Xelus clients

and brokers are provided by Health Continuum.

www.healthcontinuum.co.za

Office Sharecall Number:0861-4-XELUS (93587)

Administrative QueriesCorlea Kruger | E-mail: corlea@xelus.co.za

Verner Strauss | E-mail: admin@xelus.co.za

Chane Coetzer | E-mail: admin2@xelus.co.za

Sheinel Naidoo | E-mail: admin9@xelus.co.za

Michelle van Rooyen | E-mail: admin4@xelus.co.za

General Queriesinfo@xelus.co.za

New application and application queries applications@xelus.co.za

New claims and claim queries claims@xelus.co.za

Complaintsescalations@xelus.co.za

12

Consultant Tel Cell Email

Thandi Zulu 011 759 9632 072 517 7008 thandi@healthcontinuum.co.za

Laura Hill 011 759 9634 072 455 7162 laura@healthcontinuum.co.za

Charlene Eaton 011 759 9631 076 454 7650 charlene@healthcontinuum.co.za

Warren Maxwell-Pear 011 759 9633 074 474 1983 warren@healthcontinuum.co.za

Robyn Gould 011 759 9630 083 453 3621 robyn@healthcontinuum.co.za

Marna Mouton 031 561 7027 082 432 3178 marna@healthcontinuum.co.za

Corrine Clifford-Mundy 021 461 3909 073 143 3694 corrine@healthcontinuum.co.za

Distribution Services

Waiting Periods

NO NO

If a Window Period Concession has been provided and the member answers the

medical question as:

New employees of voluntary groups of 20+ members and the member answers the

medical question as:

Quick Overview

YES YES

ONLY APPLIES TO VOLUNTARY GROUPS OF 20 OR MORE MEMBERS

For individuals, groups less than 20 and members who apply more than 2 months after commencing employment (unless within a window period concession), medical

underwriting will be applied as per section 4.2

All waiting periods

will be waived.

Only the 3 month

general waiting

period will be

waived. The two x

12 month waiting

periods will still

apply (pre-existing

& pregnancy).

All the waiting

periods will apply

(3 months general,

12 months

pre-existing,

12 months

pregnancy)

11. Waiting Period Overview

All waiting periods

will be waived.

SPECIALISED RISK SOLUTIONS

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SPECIALISED RISK SOLUTIONS

Tel: 0861 4 XELUS (93587) • Fax: 086 501 8521 • Email: info@xelus.co.za • www.xelus.co.zaXelus is an authorised �nancial services provider (FSP No: 36931)

Underwritten by Centriq Insurance (Ltd)