Health+^® Plan information: waiting periods, exclusions and critical illness definitions

A benefit will not be paid if the insured event is caused or accelerated directly or indirectly by:

• • war, civil commotion or terrorist activity
  • wilful exposure to danger
  • radioactivity or a nuclear explosion
  • use of a drug not prescribed by a registered medical practitioner
  • use of alcohol above the legal limit
  • attempted suicide, or self-inflicted injuries (wilfully or through gross negligence), or if the insured event happens while the life insured commits a criminal activity.

Benefits are only paid for hospitalization that is medically necessary in the opinion of our chief medical officer and recommended by a qualified medical physician registered with the Health Professional Council of South Africa.

The following is specifically not covered:

• • The terms and conditions of this policy are not met; or
  • hospitalisation is not in a hospital as defined under this policy; or
  • hospitalisation is in any institution, hospital or clinic that is primarily a rest or convalescent (recovery), rehabilitation or step-down facility, or a place for custodial care; or
  • hospitalisation is for elective or cosmetic purposes; or
  • the claim is fraudulent or information has been misrepresented in any way; or
  • you do not submit the required documentation as requested during the assessment process; or
  • the doctor’s motivation for admission is not comprehensive and does not include the confirmed diagnosis (and how it was reached), the treatment prescribed and confirmation of why in-patient treatment was essential and could not be treated as an outpatient; or
  • you wilfully or deliberately expose yourself to danger (except in an attempt to save human life); or
  • you are living permanently outside of the Republic of South Africa.
    
    

The following hospitalisations are specifically not covered:

• • Any psychological or psychiatric condition or disorder or its consequences; or
  • Self-inflicted injuries or attempted suicide; or
  • Participation in any illegal or criminal activities; or
  • Where the cause of admission arose from any drug or alcohol addiction or dependency; or
  • Any diagnostic or surgical procedures, physical examinations or investigations where there are no objective signs, symptoms or impairments; or
  • Dental or optical conditions, except as a result of an injury; or
  • Soft tissue injuries – except where ligament or tendon damage is confirmed and requires surgical intervention during the current admission; or
  • Abortion that is not medically necessary; or
  • Non-compliance with treatment where, in our opinion, the cause of admission is as a result of or is exaggerated by non-compliance with standard, prescribed treatment; or
  • Investigations of pain or pain-related conditions where a diagnosis cannot be confirmed by supporting test results, regardless of treatment received and that includes, but is not limited to, admission for bed rest, physio, medication, intravenous medication etc.; or
  • Admission where, in our opinion, treatment could have been provided as an outpatient or where admission beyond the deferred period has not been substantiated; or
  • Treatment for infertility; or
  • Treatment for obesity.

Yes, there is. Benefits will not be paid for claims within three months after the cover for that life insured began.  This is known as a waiting period. No waiting periods apply for hospitalization because of an accident. Benefits will also not be paid if the start date of the hospitalization falls within the waiting period, and hospitalization continues beyond the waiting period.

Condition-specific waiting periods (exclusions for pre-existing conditions):

Any injuries, illnesses, or conditions as defined below, of which any life insured was aware or was diagnosed with within the 12 months before the inception date of the policy and which lead to hospitalisation in the first 12 months of the policy. This includes any medical care, advice, assistance or treatment that the life insured received (or should reasonably have received), or was recommended to receive, for these conditions within the 12 months before inception of the policy. 

Any pre-existing condition that results in admission for a procedure or treatment in the specified time period, will not be covered. For example: where a medical procedure is claimed for (e.g. hip replacement), the underlying diagnosis will be used to consider whether it is a pre-existing condition or not (e.g. osteoarthritis of the hip). 

The insured person may not claim for the specific conditions that are included below during the first 12 (twelve) months after the policy start date if they were found to be pre-existing:

• Chronic conditions (diabetes, hypertension, epilepsy, anaemia, autoimmune conditions, tuberculosis, gout, congenital conditions, genetic conditions or any other condition that satisfies the definition of a chronic condition as defined below)
• Digestive system (gastric ulcers, gastroesophageal reflux disease (GORD), hernias, irritable bowel syndrome, diverticulitis, Crohn’s disease, hepatitis, gastritis, gastroenteritis or any gastrointestinal infection)
• Heart conditions (heart attack/myocardial infarction, heart failure, angina, cardiomyopathy, heart valve disorders, arrhythmias, ischaemic heart disease, atherosclerosis).
• Back and spinal conditions (back pain, neck pain, muscle spasms, spondylosis, spinal stenosis, intervertebral disc disorders/diseases).
• Bone and joint disorders (arthritis, fractures, joint replacements, joint dislocations, tendon injuries).
• Male and female reproductive system disorders (uterine fibroids, endometriosis, prostatitis, varicocele, abnormal uterine bleeding, pelvic inflammatory disease).
• Lung conditions (asthma, pneumonia, tuberculosis, chronic obstructive pulmonary disease (COPD), emphysema, bronchitis).
• Cancer (malignant neoplasms, benign neoplasms, leukaemia, lymphoma).
• Kidney or bladder diseases (chronic kidney disease, kidney failure, kidney stones, nephritis, urinary tract infections)
• Brain and nerve disorders (strokes, paralysis, meningitis, neurodegenerative disorders, Parkinson’s disease, nerve injuries; multiple sclerosis). 
• Infections (cellulitis, septicaemia, skin ulcers/abscesses, pressure sores, herpes zoster/shingles).
• Venous conditions (varicose veins, venous ulcers, deep vein thrombosis).
  
  
  

Chronic conditions are defined as conditions or illnesses where treatment or intervention is required for a continuous period of at least three months. Examples include but are not limited to: diabetes, hypertension, asthma, epilepsy, HIV.
   

• Lives insured are covered for up to 30 days per hospitalisation event, provided that the hospitalisation has been deemed medically necessary and complies with all the policy terms.
• Benefit payments will only be made for a maximum of 180 days in a policy year over all the lives covered.
• For the conditions listed below, benefit payments are limited to a maximum of 5 days per condition, per policy year for each life insured under the policy:
  
  
• 1. 1. Gynaecological: Pelvic inflammatory disease, fibroids or the symptoms thereof, abnormal uterine bleeding.
     2. Digestive: Gastritis, gastrointestinal infections or the symptoms thereof, peptic ulcer disease.
     3. Pain: Diagnosis or treatment of pain or pain-related conditions.
     4. Minor infections: Minor infections including but not limited to cellulitis, tonsillitis, sinus-related conditions, ear infections, upper and lower respiratory tract, bladder or urinary tract infections.
        
        
        
• Chronic conditions: Admissions for any chronic condition as defined in the policy, are limited to 15 days per life insured, per policy year.
• Pressure sores: Admissions for the treatment of pressure sores are limited to 30 days per life insured, per policy year.
  
  

NB: The above time periods should not be regarded as guaranteed payment periods. Any claim received for these conditions will still be assessed in accordance with the policy terms and conditions and will be subject to all evidence confirming that admission was medically necessary beyond the deferred period and was supported by objective signs and symptoms. The maximum number of days that the Health+ Cash benefit can be claimed over the lifetime of the policy is 540. This is the combined number of days for all lives insured

---

 

Benefits within South Africa

Hospitalisations at any registered hospital in the Republic of South Africa are covered.

---

 

What is meant by a hospital?

A hospital is defined as an institution which:

• is recognized by the Hospital Association of South Africa (HASA);
• is licensed in accordance with the applicable laws of the jurisdiction in which it is located;
• is primarily engaged in providing, for compensation from its patients, diagnostic, medical and surgical facilities for the care and treatment of injured or sick persons;
• has staff of one or more physicians available at all times;
• has 24 hour a day nursing service by registered graduate nurses under the permanent supervision of the physician in charge;
• maintains in-patient facilities;
• maintains a daily medical record for each of its patients, and does not include any of the following institutions:
  • rest or convalescent facilities, places for custodial care, facilities for the aged, rehabilitation clinics for alcoholics or drug addicts, institutions for the treatment of psychiatric or mental disorders, nursing homes, even if it is registered as a hospital or clinic, or hospices.

A medical practitioner or specialist must be registered with the Health Professional Council of South Africa. The medical practitioner or specialist who provides information on a life insured’s medical condition, when he or she is making a claim, cannot be the life insured or the spouse or another relative of the life insured. The medical specialist must be of the correct discipline to treat the condition which resulted in hospitalization.

Table A

 

 

1) Heart attack

 

A Heart Attack or Acute Myocardial Infarction (MI) is defined as acute myocardial injury confirmed by a certified physician as having occurred as a direct consequence of acute myocardial ischemia resulting from inadequate blood supply to the heart.

 

Heart attack of severity level A in terms of the SCIDEP definitions are covered.

 

Level A: Heart attack with severe permanent impairment in function

 

A heart attack that meets the criteria as defined below, with permanent impairment in one or more of the following functional criteria, as measured 6 weeks post-infarction:

 

 

Notes:

1. If more than one functional criterion is impaired, but their values do not conform to one severity level (for example one impaired value is Level A and another Level B), the final severity level should be determined by giving preference to the more objective criteria, i.e. in the following order:

 

1. LVEF

2. LVEDD

3. Ultrasound FS

4. METS

5. NYHA

 

Heart attack criteria:

 

This is defined as the death of heart muscle, due to inadequate blood supply, as evidenced by any of the following combinations of criteria:

 

1. Compatible clinical symptoms AND raised cardiac biomarkers

OR

2. Compatible clinical symptoms AND new pathological Q-waves on ECG as defined in Annexure A (b)

OR

3. New pathological Q-waves on ECG as defined in Annexure A (b) AND raised cardiac biomarkers

OR

4. ST-segment and T-wave changes on ECG indicative of myocardial injury as defined in Annexure A (a) AND raised cardiac biomarkers

 

Where raised cardiac biomarkers are referenced above, they are defined as any one of the following Troponin Markers:

Sensitive Troponin Markers:

 

 

* Use the relevant manufacturer’s assay (test) or equivalent as it appears on the laboratory report.

**Values represent multiples of the World Health Organisation (WHO) MI rule in levels and not the 99th percentile values (upper limit of normal) as quoted on the laboratory result.

 

Conventional Troponin Markers:

 

 

*** or equivalent threshold with other Troponin I methods

 

2) Stroke

 

Death of brain tissue due to inadequate blood supply or haemorrhage within the skull resulting in neurological deficit, confirmed by neuro-imaging investigation and appropriate clinical findings by a specialist neurologist. Symptoms and signs as well as imaging must confirm a new stroke.

 

For the above definition, the following are not covered:

• Transient ischaemic attack; this is defined as a transient episode of neurologic dysfunction (irrespective of duration) caused by focal brain, spinal cord, or retinal ischemia, without acute infarction (on neuroimaging investigations)

• Vascular disease affecting the eye or optic nerve;

• Migraine and vestibular disorders;

• Traumatic injury to brain tissue or blood vessels.

 

Severity levels will be assessed by a full neurological examination by a specialist neurologist any time after three months.

 

Stroke of severity level A in terms of the SCIDEP definitions are covered.

 

Level A: Stroke with severe impairment

 

Needs constant assistance, as measured by:

• the inability to do 3 or more basic ADLs, or

• a Whole Person Impairment (WPI) of greater than 35%.

 

WPI figures are calculated as per the latest American Medical Association Guides to the Evaluation of Permanent Impairment.

 

Basic Activities of Daily Living (ADL)

• Bathing – the ability to wash/bathe oneself independently
• Transferring – the ability to move oneself from a bed to a chair or from a bed to a toilet independently
• Dressing – the ability to take off and put on ones clothes independently
• Eating - the ability to feed oneself independently. This does not include the making of food
• Toileting – the ability to use a toilet and cleanse oneself thereafter, independently
• Locomotion on a level surface – the ability to walk on a flat surface, independently
• Locomotion on an incline – the ability to walk up a gentle slope, or a flight of steps independently

 

3) Cancer

 

A malignant tumour positively diagnosed with histological confirmation and characterised by the uncontrolled growth of malignant cells and invasion of tissue. The term malignant tumour includes leukaemia, lymphoma and sarcoma. The classifications are based on the latest edition of the AJCC Cancer Staging Manual. Pathological staging overrides the clinical staging.

 

The following conditions are excluded from this definition:

• Tumours which are histologically described as benign, pre-malignant, low malignant potential. Any tumour classified as carcinoma in-situ (Tis) or (Ta) by the latest edition of the AJCC Cancer Staging Manual 
• All tumours of the prostate unless histologically classified as having a Gleason score of 7 or more or having progressed to at least clinical TNM classification T2N0M0. 
• All non-melanoma skin cancers are excluded. A malignant melanoma that has been histologically classified as TINOMO or higher is covered under this definition. 
• All myelodysplastic syndromes and myeloproliferative neoplasms including but not limited to, essential thrombocythemia, primary myelofibrosis, polycythemia vera 
• Primary cutaneous lymphoma and dermatofibrosarcoma which are confined to the skin and which have not spread to the lymph nodes or distant sites. 
• All cancers only identified from tumour cells, pieces of DNA, or any other biomarkers, any of which may be present in the blood, saliva, urine, or other bodily fluids, including, but not limited to, tests known as “liquid biopsies”. 

 

Cancers are generally classified by severity into four stages. However, brain and prostate cancer, leukaemia and lymphoma do not conform to this general classification. Therefore, additional tiering levels are provided for these cancers.

 

Cancer of severity level A in terms of the SCIDEP definitions are covered.

 

The following is covered:

 

All cancers except prostate, leukaemia, lymphoma and brain tumours

 

The levels are correlated to the general classification used by the American Joint Committee for Cancer for the type of cancer involved:

 

  Level A – Stage 4 cancer

 

Prostate cancer

 

Stage 4 – any T, N1 – 3, M0 any Gleason

Stage 4 – any T, any N, M1 any Gleason

 

Leukaemia and lymphoma

 

The benefit will pay for any one of the following diagnoses:

• Acute myeloid leukaemia.
• Chronic lymphocytic leukaemia (stage III or IV on the Rai classification, Binet C, very high risk CLL-IPI).
• Chronic myeloid leukaemia (requiring bone marrow transplant).
• Acute lymphocytic leukaemia (adults)
• Hodgkins/non-Hodgkins lymphoma stage IV on Ann Arbor classification system.
• Multiple myeloma stage III on the Durie-Salmon Scale.

Brain tumours

• WHO grade IV (on diagnosis)

4) Coronary Artery Bypass Grafting (CABG)

 

The undergoing of surgery, regardless of method of surgical access, to correct the narrowing of, or blockage to three or more coronary arteries, by means of a by-pass graft.

Excluded: Closed coronary artery procedures, including but not limited to coronary angioplasty, stent insertion and all other intra-vascular catheter-based procedures

 

5) Kidney failure

 

Chronic, irreversible end-stage renal failure of both kidneys, for which regular renal dialysis or peritoneal dialysis is required on a long-term basis – at least six months continuously.  The diagnosis must be confirmed by a nephrologist.

 

6) Paraplegia

 

Total and irreversible loss of the use of both legs. A neurosurgeon or neurologist must confirm the diagnosis.

 

For the above definition, the following are not covered:

Paralysis due to psychological disorders.

 

7) Major organ or tissue transplant

 

The life insured receives a complete kidney, heart, lung, liver, pancreas, or bone marrow transplant. For bone-marrow transplant, this must be preceded by total marrow ablation.

 

Excluded:  Stem-cell transplants.

 

8) Coma

 

 A state of unconsciousness, with no reaction to external stimuli and internal needs, defined by a Glascow Coma Scale of 8 or less, persisting continuously for at least 96 hours and requiring intubation and mechanical ventilation, as confirmed by a neurologist or neurosurgeon.

 

Excluded: Drug, alcohol or pharmacologically induced comas.