Benefits are not paid in the following cases
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 are 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:
- Hospitalization for the investigation or treatment of infertility;
- Hospitalization undertaken in cure clinics or hydros, rehabilitation, or sub-acute or step-down facilities;
- Hospitalization undertaken as a preventive measure, or for quarantine purposes;
- Hospitalization for elective procedures or for purposes of investigation;
- Hospitalization due to cosmetic or plastic surgery except in the case of major reconstruction after injury, that is medically necessary.
The following hospitalizations are also specifically not covered:
- Hospitalization for dental or optical conditions and treatment, except as a result of an injury;
- Hospitalization for cosmetic procedures or investigations;
- Hospitalization arising from or following alcohol or drug dependence syndrome including treatment of any medical condition which, in the opinion of our consulting physician, is considered to be either an underlying cause of, or directly attributable to, alcohol or drug dependence syndrome;
- Hospitalization because of self-inflicted injury or attempted suicide;
- All mental illnesses or disorders including, but not restricted to, eating disorders, anxiety disorders, affective disorders, or personality disorders;
- Hospitalization for the investigation or treatment of obesity;
- Hospitalization for the investigation of pain or pain-related conditions and the treatment thereof (which would include bed rest, traction, physiotherapy, medication or intravenous medication);
- Hospitalization for infertility treatments;
- Hospitalization for abortion that is not medically necessary.
The waiting periods that apply to your Health+ benefit
- 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 period:
- Specific pre-existing conditions:
For the first 12 months of a benefit, no benefit is payable in respect of a specific pre-existing condition. A specific pre-existing condition shall mean any of the following listed conditions that the life insured has been diagnosed with and received or was recommended to receive medical advice, care or treatment for within the 12 months preceding the start of their cover. Chronic in relation to any medical condition means that it is recurrent and has required treatment on at least three instances or for a period of three consecutive months.
- Chronic conditions (diabetes, hypertension, epilepsy, anaemia, autoimmune conditions and tuberculosis).
- Digestive system (gastrointestinal tract infections, recurrent gastritis, abdominal pain, gastric ulcers, gastroesophageal reflux disease, hernia, irritable bowel syndrome, colitis, Crohn`s disease, constipation and hepatitis).
- Heart conditions (heart attack, heart failure, cardiomyopathy, heart valve disorders, arrhythmias, ischaemic heart disease, angina and atrial fibrillation).
- Back problems (mechanical or neurological back pain, neck pain, spondylosis, spinal stenosis, intervertebral disc disorders/diseases, sciatica, paraplegia and tetraplegia).
- Bone and joint disorders (arthritis, fractures, cartilage disorders, joint replacements, joint dislocations, tendonitis, tendon injuries or ruptures, avascular necrosis, contractures and bursitis).
- Male and female reproductive system disorders (abnormal uterine bleeding, uterine fibroids, cysts, pelvic inflammatory disease, endometriosis, prostatitis, prostatic hypertrophy, orchitis, and erectile dysfunction).
- Pregnancy and childbirth-related hospitalization.
- Lung conditions (asthma, pneumonia, sarcoidosis, lung fibrosis, tuberculosis, emphysema, chronic obstructive pulmonary disease and chronic bronchitis).
- Cancer (malignant neoplasms, benign neoplasms, leukaemia, lymphoma, haematological disorders, in situ lesions and cervical intraepithelial neoplasia (CIN) lesions).
- Kidney or bladder diseases (chronic kidney disease, renal cysts, kidney failure, urinary tract infections, kidney stones and nephritis).
- Brain and nerve disorders (strokes, paralysis, meningitis, neurodegenerative disorders, hydrocephaly and neurofibromatosis).
- Venous or circulatory conditions (varicose veins, vascular necrosis, chronic venous ulcers and pressure sores).
- Congenital conditions (cerebral palsy, cleft lip/palate, club foot, limb length discrepancies and cardiac malformations).
- Infections (cellulitis, herpes stomatitis, septicaemia, pressure sores, skin ulcers/abscesses, herpes zoster, tonsillitis, sinusitis, ear infections and human papillomavirus (HPV)).
- If this policy replaces another policy with similar benefits you ended within 90 days of this policy starting, then the condition-specific waiting period will only be the unexpired part of the waiting under the policy that ended.
- The maximum benefit amount that can be paid out under this benefit is R20 000 per life insured per policy year, irrespective of the number of hospital admissions in respect of the life insured in the policy year.
Benefits within South Africa
Hospitalizations 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 recognised 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.