2022 Policy Document JUNIOR
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Table of Contents Page Hospital pre-authorisation 0861 11 00 33 1. Introduction 1 2. Welcome to Affinity Health 1 3. About your Policy 1 24-Hour Emergency 4. Definitions 2 0861 11 00 33 (Option 2) 5. Premium Payments 7 6. Waiting Periods 7 7. Benefits 8 8. General Provisions 19 9. Exclusions 20 www.affinityhealth.co.za 10. Claims 21 11. Amendment/Upgrade/Cancellation Procedure 22 affinityhealthcoza 12. Dispute Resolution 22 13. Sharing of Insurance Information 22 Schedule 1 22 Schedule 2 23 Schedule 3 23 Schedule 4 23 This is not a medical scheme and the cover is not the same as that of a medical scheme. This Policy is not a substitute for medical scheme membership. Subject to Demarcation Regulations, the Assurer does not refuse membership on the basis of any means of discrimination.
1. Introduction 2.3 This Policy Wording includes important information about the Policy purchased. The Owner must please take time to read through this 1.1 This Affinity Health Policy is managed and administered by National Risk document and keep it in a safe place. Affinity’s dedicated team of client Managers (Pty) Ltd (Registration Number 2016/109644/07), a registered services staff are on hand to assist with any questions about the Policy. Financial Service Provider (FSP Number 47132) (NRM). NRM is the Underwriting Manager and Binder Holder. 2.4 Policyholders that are unhappy with the services rendered, should refer to the Disclosure Notice that is included in the Welcome Pack for guidance 1.2 Lion of Africa Life Assurance Company Limited (Registration Number on their rights and how to best proceed. 1942/015587/06), a registered Life Assurer and authorised Financial Service Provider (FSP 15283). 2.5 Affinity is dedicated to meet the needs of clients whilst improving business and keeping the community at the heart of all we do. We strive to have a 1.3 This long-term insurance Policy is regulated by the Financial Sector long and mutually beneficial relationship for many years. Conduct Authority and the Council for Medical Schemes. This is, however, - The Affinity Health Team not a Medical Scheme and the cover is not the same as that of a Medical Scheme. This Policy is not a substitute for a Medical Scheme Membership. 3. About your Policy 1.4 Subject to Demarcation Regulations, the Assurer does not refuse membership on the basis of any means of discrimination. 3.1 The Affinity Health product provides you with simple, cost-effective and 1.5 This Policy Document should be read in conjunction with your Policy reliable health insurance through our extensive Designated Service Schedule, as not all cover referred to in the Policy Wording may be Provider Network (DSPs). The insurance has been chosen by the applicable to the Option that you have selected. Policyholder/Owner and is identified as the Defined Cover. Details of the Affinity Health Plan Benefits will appear in the Policy Schedule. 2. Welcome to Affinity Health 3.2 This contract consists of three parts: 3.2.1 The application form completed and signed by the Owner and/or 2.1 The customers, and all other stakeholders benefit if customers are treated by the Representative on the Assured Person(s)’ behalf (if the fairly in all aspects of the business. This is why NRM has allocated the Assured Person(s) and the Owner are not the same person) administration and servicing of your Policy to the Affinity Health Team through a recorded telephonic conversation; (Affinity) to assist in all your queries. 3.2.2 The Policy Schedule which is issued to the Owner electronically; 2.2 Affinity commits to: and 2.2.1 provide customers with clear information about the products and 3.2.3 This document, which contains all the terms and conditions of services that are offered, including fees and charges; this life assurance contract. 2.2.2 provide customers with information and further clarification on 3.3 The Disclosure Notice, which provides a summary of all the important anything that they do not understand in relation to products and details of this contract as well as details of where and how to lodge a services; complaint, is included in your Welcome Pack. It does not form part of the 2.2.3 give customers access to a formal complaint procedure should contract, but contains important information for the attention of the they become unhappy with the service provided; Owner and Assured Person(s). 2.2.4 act fairly, reasonably and responsibly in all dealings with 3.4 Detailed information on certain Benefits available on the product and customers; Option you have purchased, is specified in the Affinity Health Benefit Guides, which are accessible through our website, 2.2.5 act honestly and, to the best of their ability, ensure that brokers, www.affinityhealth.co.za. Alternatively you can contact our Client Services and all suppliers of goods and services that Affinity does business department telephonically on 0861 11 00 33 or via email at with, do the same; info@affinityhealth.co.za to obtain an electronic copy. 2.2.6 treat all the Policyholders’ personal information as private and 3.5 The Assurer Agrees to: confidential, and run secure and reliable systems; and 3.5.1 Maintain the Policy in force for as long as the Owner and/or 2.2.7 train staff to make sure that the procedures they follow reflect Assured Person(s) meets all the Policy's terms and conditions. the commitments set out in Affinity’s code of conduct. 1
3.5.2 Manage the Policy in accordance with the instructions provided 4.1.3 “Activities of daily living (ADL)” is a term used in healthcare to by the Owner on the application form/application voice file or in refer to people's daily self-care activities that are required to any subsequent written or recorded telephonic instruction independently care for oneself such as washing, dressing, provided by the Owner and/or Life Assured in the format feeding, toileting, mobility, transferring and communication. A required. person's ability or inability to perform ADL is used to measure their functional status or the degree of assistance required, 3.5.3 Pay the Policy Benefits to the applicable service provider upon a particularly regarding people post hospitalisation due to an Defined Event(s), provided that all conditions have been adhered Accident or Illness. to. 4.1.4 “Acute Medication” means medication that meets the following 3.5.4 Notify the Owner of any exclusions applicable to the Policy. requirements: 3.6 The Assured Person(s) and Owner agrees to: 4.1.4.1 is within the Affinity Health Medication Formulary, as amended from time to time and is prescribed by a 3.6.1 Timeously provide Affinity with all information requested. Failure medical practitioner for diseases or conditions that to do so may delay or prevent payment of any Policy Benefit. have a rapid onset and severe symptoms; and 3.6.2 Pay each and every premium, consecutively due on the Policy as 4.1.4.2 is prescribed for less than 90 (ninety) days. agreed and on time. Failure to do so may result in the Policy lapsing. Affinity will notify the Owner of any impending lapse. The 4.1.5 “Admission” means admission into a Hospital as an inpatient. Policy will lapse when the premium remains unpaid for a period of more than 45 (forty- five) calendar days. 4.1.6 “Adult Dependant” means a person other than a Spouse of the Policyholder who is wholly or partly dependent on the 3.6.3 Notify Affinity of any change in postal address, residential Policyholder for financial support including: address or contact details, or other applicable information. Please note that Affinity will always communicate with the Owner 4.1.6.1 a child of the Policyholder over the age of 21 (twenty- using their last known details. one) years; 3.6.4 Us obtaining personal information relating to the Assured 4.1.6.2 an immediate family member (sibling or parent) over Person(s)’ historical and future medical information. the age of 21 (twenty-one) years; or 4.1.6.3 the second and any additional Spouse of a Member 4. Definitions under a customary union or under a union recognised as marriage under the tenets of any 4.1 In this Policy, unless the circumstances indicate a different intention, the religion. following words and expressions bear the meanings given to them and similar expressions bear corresponding meanings – 4.1.7 “Affinity” means the company named Affinity Health (Pty) Ltd. 4.1.1 “Accident” means an unforeseen, unfortunate, sudden, unusual, 4.1.8 “Affinity Health/We/Us/Our” means the Health Benefit Cover specific incident or event which could not reasonably have been Product underwritten by National Risk Managers (Pty) Ltd, a expected to occur and was not planned or happened registered Financial Services Provider (FSP Number 47132) under unintentionally at an identifiable time and place resulting in contract from the Assurer. Bodily Injury due to violent, external and visible means during the period of the Policy, such as a motor vehicle accident. 4.1.9 “Affinity Health Rate” means the rate Affinity Health pays for healthcare services provided by hospitals, pharmacies, 4.1.2 “Active Cover” means that the cover and Benefits provided in healthcare professionals and other providers of relevant health terms of this Policy are in force and have available Benefits, services. subject to the terms and conditions contained in the Policy Wording. 4.1.10 “Affinity Health Rate for Medicine” means the rate that Affinity pays for medicine. It is the Single Exit Price of medicine plus the relevant dispensing fee according to the Affinity Health Formulary. 2
4.1.11 “Annual Benefit Limit” means the cap on the Member’s Benefits 4.1.23 “Child Dependant” means the named child of a Policyholder that Affinity will pay in a calendar year. Annual Limits can be under the age of 21 (twenty-one) years, including: placed either on specific services as an annual amount for covered services or on the number of visits that will be covered 4.1.23.1 a natural child; for a particular service. The number of Dependants on the Policy will determine the amount as well as the type of Benefit. After the 4.1.23.2 a stepchild; Annual Benefit Limit is reached, all additional associated healthcare expenses will be for the Member’s account. 4.1.23.3 a legally adopted child, including a child adopted in terms of a customary adoption under a tradition 4.1.12 “Antenatal” means the period before birth, during or relating to practiced by the people of South Africa provided that pregnancy. the child's natural parents are both deceased; 4.1.13 “Application Date” means the date on which the application for 4.1.23.4 an adoption under the tenets of any religion practiced this assurance policy is completed in its entirety and submitted to by the people of South Africa provided that the child's the Assurer for assessment. natural parents are both deceased; or 4.1.14 “Assured Person(s)” means the natural person and Policyholder 4.1.23.5 a child of a Child Dependant and/or Adult Dependant. as named on the Policy Schedule and their named Spouse and/or Dependant/s who have applied and been accepted by the 4.1.24 “Cholesterol Rapid Test” involves a droplet of blood being Assurer and whose Premium is paid and up to date and has in- placed on a specialised strip of paper to measure the amount of force life assurance cover in terms of this Policy. cholesterol in the blood. 4.1.15 “The Assurer” means Lion of Africa Life Assurance Company 4.1.25 “Chronic Medication Formulary” means the complete list of Limited, the registered Assurer with FSP Number 15283, as may procedures, prices, medication and services related to Chronic be amended from time to time. Conditions, as approved and amended from time to time by Affinity Health, which together constitutes the maximum limit of 4.1.16 “Audiometry” means a screening test performed to measure a Benefits which Affinity will be bound to pay in terms of the Policy. person’s sense of hearing. The test is performed with the use of electronic equipment. 4.1.26 “Chronic Essential Benefit (CEB)” is available to Members through an application process. This Benefit covers medication 4.1.17 “Benefit” means the Benefit amount as set out in the Policy according to the Affinity Chronic Medication List Formulary for 24 Schedule, provided by the Assurer in terms of this Policy. specific Chronic Conditions. 4.1.18 “Benefit Start Date” means the date on which the Assured 4.1.27 “Chronic Medication” means medication that meets all the Person(s) becomes entitled to Benefits. This date occurs after the following requirements: completion of initial General or specific Waiting Periods. 4.1.27.1 is within the Formulary, as amended from time to 4.1.19 “Blood Pressure Monitoring” is used as a screening tool to time, and prescribed by a network medical determine if a person may have high blood pressure that could practitioner for an uninterrupted period of at least 3 lead to additional health issues. (three) months; 4.1.20 “BMI” means Body Mass Index that takes a person’s weight and 4.1.27.2 is for a condition appearing on the list of approved height and calculates to check if that person’s weight is healthy. Chronic Conditions, as amended from time to time; BMI is used as a screening tool to indicate if a person is a weight and category that could lead to other health issues. 4.1.27.3 has been applied for in the manner and at the 4.1.21 “Cancer” means the uncontrollable growth and spread of frequency prescribed and which application has been malignant cells and the invasion and destruction of normal approved and accepted. tissue. 4.1.28 “Commencement/Commencement Date” means the date on 4.1.22 “Casualty/Emergency Room” means the Casualty or Emergency which the Policy comes into force and effect for the first time as Department of a Hospital (that is part of the Hospital or a specified in the Policy Schedule. Prior to Commencement, the separate GP practice) providing immediate treatment for Policy and contractual relationship between Affinity / The Assurer emergency cases. and the Policyholder does not exist. 3
4.1.29 “Consecutive Premiums” means monthly premiums received, 4.1.42 “Domicilium Citandi et Executandi” means the address when due, in succession and without interruption or default. nominated by a Member in the application for the purpose of receiving legal notices, documents and processes. This shall 4.1.30 “Continuation Member” means an existing spouse who include any electronic details. becomes the Policyholder after the death of the original Policyholder. 4.1.43 “Emergency Medical Condition” means a sudden and at the time, unexpected onset of a health condition that requires 4.1.31 “Contraception” means any of the activities, procedures and immediate medical or surgical treatment, where failure to provide medications which are intended to prevent pregnancy. medical or surgical treatment would result in serious impairment of bodily functions or serious dysfunction of a bodily organ or 4.1.32 “Co-payment” means an amount that the Member needs to pay part thereof or would place the person’s life in serious jeopardy. towards healthcare service. The amount can vary by the type of The Affinity Health Pre-authorisation team may ask Members for diagnostic procedure, not making use of a network service additional information to confirm the emergency. An emergency provider, or services that are not part of the various Formularies, does not necessarily require a Hospital Admission. or if the amount the service provider charges, is more than what Affinity Health will cover. If the Co-payment amount is higher 4.1.44 "Emergency Treatment" means immediate medical treatment than the amount charged for the healthcare service, Members for an emergency medical condition as defined in this document. will have to pay for the cost of the healthcare service. 4.1.45 “Exclusions” means the specific medications, treatments and 4.1.33 “C-Section” means a caesarean section, which is a surgical procedures which Affinity will not cover in terms of the Policy. procedure where incisions are made through a woman's abdomen and uterus to deliver her baby. 4.1.46 "Fair Use" means the prohibition of unnecessary and wasteful misuse of Benefits. 4.1.34 “Day” means 24 (twenty-four) consecutive hours from time of Admission. 4.1.47 “Family” includes the Main Member’s Spouse, Child Dependants and Adult Dependants added to the Policy. 4.1.35 “Day Clinic” means a facility that offers surgical procedures that do not require an overnight stay; and that is part of the Network 4.1.48 “Formulary” means the complete list of procedures, prices, Service Providers contracted with Affinity Health. medication and Service Providers, as approved and amended from time to time by Affinity Health, which together constitutes 4.1.36 “Defined Event” means the event which gives rise to the Assured the maximum limit of Benefits which Affinity will be bound to pay Person having to seek medical treatment and which will be in terms of this Policy. payable by the Assurer as set out in this document. 4.1.49 “Fraudulent Act” includes the main Member, or any Member on 4.1.37 “Designated Public Hospital” means a Public or State Hospital the Policy, or any person acting on the Member’s behalf or that is a DSP (Designated Service Provider), which Affinity is associated with the Member providing Affinity or the Assurer at contracted with. any time with inaccurate, incomplete, dishonest, false, fabricated or exaggerated information. 4.1.38 “Designated Service Provider (DSP)” means a service provider that is contracted to Affinity Health. DSPs offer preferential rates 4.1.50 “General Practitioner (GP)” means a network General and are required to be used for most Benefits and are Affinity’s Practitioner who has contracted with Affinity Health to provide first choice when its Members need diagnosis, treatment or care. the Member with the following coordinated care: primary health For certain Benefits, State Hospitals are Designated Service care, treating acute illnesses, providing preventative care, Providers. Visit www.affinityhealth.co.za to view the full list of providing health education and treating defined Chronic DSPs. Conditions. 4.1.39 “Diabetes Counselling” forms part of the Diabetes Management 4.1.51 “Glucose Monitoring” involves a droplet of blood being placed Programme, supporting high risk Diabetes patients in partnership on a specialised strip to measure the amount of sugar in the with Affinity’s Nurse Network. blood. 4.1.40 “Diagnostic Tests” means tests that assist in the detection and 4.1.52 “Grace Period” means the 15 (fifteen) day period of grace confirmation or absence of any disease, injury or any other allowed for payment of missed Premiums, prior to Policy health condition that requires medical attention. suspension/termination. 4.1.41 "Dispensing Provider" means a doctor that can supply medication to to patients from his rooms without issuing a script. 4
4.1.53 “Guarantor” means a person who assumes financial 4.1.61 “Illness” means the onset of any acute, somatic, unforeseeable, responsibility for another, i.e. the person who promises to be unpredictable Illness, including Microtrauma and Pathological financially responsible for any additional payments, shortfalls Fractures (but excluding mental Illness). A recurrence of any and/or Co-payments for the Members on this Policy. Illness, or the occurrence of a related Illness, will only be considered a separate Illness if 6 (six) months have elapsed from 4.1.54 “Heart Attack” or Myocardial Infarction (MI) is the death of, or the date of onset of the preceding Illness. damage to, an area of the heart muscle (myocardium) resulting from the reduction or from a blocked supply of blood to the heart 4.1.62 “Injury on Duty or Occupation Disease (IOD/OD)” means an muscle. unexpected occurrence, at a specific date, time and place and arising out of and in the course of the employee’s employment, 4.1.55 “Heart Block” means a delay in the normal flow of electrical resulting in personal injury or death, or when an occupational impulses that cause the heart to beat and with a Third-degree disease is contracted due to exposure at the workplace. heart block no electrical messages get through to the heart resulting in a very slow heartbeat or the heart may stop beating. 4.1.63 “Intensive Care Unit (ICU)” means a designated area of a hospital where close monitoring and life support treatments are 4.1.56 “High Care (HIC)” means a designated area of a hospital that provided for patients that are critically ill with potential or provides invasive monitoring and support for patients at risk of established organ failure. Staffed with one nurse per patient and developing organ failure and/or where the predicted risk of usually with a doctor present in the unit 24 hours per day. clinical deterioration is high or unknown. They are staffed with Admission in ICU is subject to Pre-authorisation and is based on one nurse to two patients. Admission in HIC is subject to Pre- clinical guidelines and protocols. authorisation and is based on clinical guidelines and protocols. 4.1.64 “Lapse/Lapsed Cover” means that the cover and Benefits 4.1.57 “HIV Care Programme” means the Affinity Health HIV Care provided in terms of this Policy have been suspended due to Programme that assists Members on the programme to manage non-payment of Premiums due and are no longer available. their condition. 4.1.65 “LASIK Eye Surgery” means a type of laser eye surgery that can 4.1.58 “Home Nursing” means care for Members and Dependants that correct vision in people who are nearsighted, farsighted or have are recovering or rehabilitating after discharge from Hospital and astigmatism. who are unable to perform all activities of daily living in the comfort of their own home. 4.1.66 "Major trauma" means a specified life-threatening injury, caused by external or violent means, that requires immediate 4.1.59 “Hospital” means an establishment which meets the following treatment in ICU including ventilation and/or immediate surgery. requirements: 4.1.67 “Maternity Benefit” refers to the Benefits that are provided for 4.1.59.1 holds a licence as a Private or Public Hospital, Day maternity care during and immediately before and after birth at Clinic, or Sub-Acute Facility; the Affinity Health Rate. There are Maternity Benefits available on the Day-to-Day, Hospital and Combined Plan. It is important to 4.1.59.2 operates primarily for the reception, care and note that Benefits for a newborn baby will only be effective after treatment of sick, ailing or injured persons as the registration of the baby as a Dependant on this Policy. inpatients; 4.1.68 “Maternity Programme” means the Affinity Maternity 4.1.59.3 provides organised facilities for diagnosis and surgical Programme where members are advised to register their treatment; pregnancy by by contacting 0861 11 0033 or emailing info@affinityhealth.co.za as soon as they are aware that they are 4.1.59.4 is not primarily a rest or convalescent home or similar pregnant. Once activated the Member will have immediate establishment and is not, other than incidentally, a support for Telehealth Advice and Support; and a pregnancy place for rehabilitation of alcoholics or drug addicts. health record. Pregnant members can also Pre-authorise their 4.1.60 “ICD-10 Code” - ICD-10 stands for International Classification of Hospital Admission for the birth of their baby through the Affinity Diseases and Related Health Problems (10th Revision). It is a Maternity Programme by calling 0861 210 211. clinical coding system developed by the World Health 4.1.69 “Medical Society” means the group of medical centres that Organisation (WHO) translating medical and health information provide basic and primary healthcare. into codes. The codes describe diseases, signs and symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases. 5
4.1.70 “Medicine” means a substance registered under the Medicines 4.1.84 “Out-of-Network Providers” means providers not on the Affinity and Related Substances Control Act 1965, as amended from time Health Network or, providers that have no business relationship to time, and within the Formulary. with Affinity Health. Costs incurred for most out-of-network providers are not reimbursed unless specifically Pre-authorised 4.1.71 “Medicine Formulary” is a specified list of medications covered per event. by Affinity Health. Affinity Health does not provide cover for medication not on the Formulary. 4.1.85 “Over-the-counter Medication” means medication that can be sold directly to a patient without the need for a prescription and 4.1.72 “Member” means the Member or Policyholder as named on the is subject to Pre-authorisation by the Nurse Practitioner. Policy Schedule and their Dependants who have applied and been accepted by the Assurer and whose Premium is paid and up 4.1.86 "Pathological Fracture" means an injury caused by a disease. to date and thus includes each individual assured under this Policy. 4.1.87 “Payment Arrangements” means that Affinity has payment arrangements in place with specific healthcare professionals to 4.1.73 "Microtrauma" means injuries resulting from frequent, repeated pay them in full at an agreed rate. use of a part of the body. 4.1.88 “Per diem” means the amount paid per day for certain Benefits 4.1.74 "MRSA" means Methicillin-resistant Staphylococcus aureus, this is of the specific Policy selected, where applicable. a bacteria that causes infections in different parts of the body and is difficult to treat because it is resistant to most antibiotics. 4.1.89 "Planned Procedures" means surgical procedures that can be planned and/or delayed for days or weeks, including serious 4.1.75 “Neonatal” means newborn children up to 4 (four) weeks after semi-urgent and non-urgent surgery. birth. 4.1.90 “Policy” means the Assurance Agreement concluded between 4.1.76 “Network Day Clinic” means a registered Day Clinic that is part the Assurer and the Policyholder in respect of the Benefits of Affinity Health's network. underwritten by the Assurer and set out in the Policy Schedule. 4.1.77 “Network Dentist” means a dentist that is part of Affinity 4.1.91 “Policyholder” means the person who applied for the Assurance Health’s appointed Dentist Network. Cover under this Policy and is included in the definition of Member. 4.1.78 “Network Provider” means the service providers contracted or who have an ongoing business relationship with Affinity Health. 4.1.92 “Policy Schedule” means the confirmation of Benefits and These providers offer preferential rates and are required to be Assurance Amounts payable for a Defined Event, issued to the used for most Benefits. A Network Provider is also called a Policyholder in terms of section 48 of the Long-Term Insurance Designated Service Provider or DSP. Act, which should be read in conjunction with this document. 4.1.79 “Network GP” means a general practitioner that is part of Affinity 4.1.93 “Postnatal” means the period immediately after the birth of a Health’s appointed GP network. child. 4.1.80 “Non-emergency Conditions” means conditions that do not 4.1.94 "Pre-authorisation" means the act of contacting and obtaining meet Affinity Health’s Emergency Definition but that do require authorisation from Affinity Health before utilising certain medical care within 4 to 24 hours based on international Benefits. emergency triage protocols. 4.1.95 “Pre-existing Condition” means any personal Illness, injury or 4.1.81 “Nurse Practitioner” These are the qualified nurses, registered health condition for which the Assured Person(s) received or with the South African Nursing Council (SANC) or the Primary sought medical and/or dental advice, diagnosis, care or treatment Health Medical Staff Council of South Africa (HPCSA), who provide in the 12 (twelve) month period ending on the Commencement primary healthcare to patients at the Medical Society Centres or Date. via the Telehealth consulting line. 4.1.96 “Premium/Contribution” means the Premium payable to the 4.1.82 “Ophthalmologist” means a medical doctor who has specialised Assurer on a monthly basis in terms of this Policy to secure the in eye and vision care and is able to perform eye surgery in a Benefits. Hospital. 4.1.97 “Professional Sport” means a sporting activity in which the 4.1.83 “Option” means a plan registered under Affinity Health, which Assured Person(s) engages and from which such Assured offers a specific structure of Benefits. Person(s) derives the majority of their annual income. 6
4.1.98 “Related accounts” means any account other than the Hospital 4.2 Any reference to the singular includes the plural and vice versa. account for in-hospital care. This could include the gynaecologist/ obstetrician and anaesthetist's account. 4.3 Any reference to a gender includes other genders. 4.1.99 “RPL” means the National Reference Price List for Services by 4.4 The clause headings in this Policy Document have been inserted for Medical Practitioners that is part of the Master Industry Table convenience only and shall not be taken into account in its interpretation. published by the Council for Medical Schemes. 4.5 If any provision in a definition is a substantive provision conferring rights 4.1.100 “Serious Illness” means specified health conditions that have a or imposing obligations on any party, effect shall be given to it as if it were large cost and if not treated immediately, carry a high risk of a substantive clause in the body of the Policy, notwithstanding that it is mortality and may either negatively impact a person’s daily only contained in the interpretation clause. function or quality of life, like a Heart Attack, Third Degree Heart Block, Stroke or Cancer. 4.6 This Policy shall be governed by, construed and interpreted in accordance with the laws of the Republic of South Africa. 4.1.101 “Service Provider” means registered healthcare providers and institutions that are part of Affinity’s appointed Network for the 5. Premium Payments provision of relevant healthcare services. 4.1.102 “Shortfall” means the difference between the Benefit amount 5.1 All Premiums are payable monthly in advance by, or on behalf of, the available that will be paid by Affinity and the amount that is Owner, on the day of the month selected by the Policyholder, from the list charged by the Service Provider. The Member is responsible for of dates provided. the payment of the Shortfall. 5.2 If the Premium is not paid on the payment date selected, a 15 (fifteen) day 4.1.103 “Snellen eye screening” is a basic visual acuity assessment used Grace Period will be applicable. The Policy will be suspended during the to measure a person's sharpness of vision. Grace Period and no claims will be payable. 4.1.104 “Spouse” means the named Spouse of a Policyholder, including 5.3 The Grace Period will commence from the second month following the any life partner. Commencement Date provided that collection of the first Premium was successful. 4.1.105 “Stroke” means the sudden death of brain cells due to lack of oxygen, caused by blockage of blood flow or rupture of an artery 5.4 The Assurer reserves the right to collect any failed or rejected Premium, to the brain. which may include a double debit, from the nominated bank account. 4.1.106 “Sub-acute Facility” means a Facility where comprehensive care 5.5 Non-payment of Premiums for 2 (two) consecutive months will result in is given to a patient who has had an Acute Illness, injury or automatic termination of this Policy and no further Benefits will be exacerbation of a disease; either immediately after or instead of payable. acute care hospitalisation, to treat specific medical conditions or 5.6 Premiums are subject to an annual increase in January of each year. The to administer any necessary medical treatments. Owner shall be notified at least 31 (thirty-one) days before the increase 4.1.107 “Territorial Limits” means within the borders of the Republic of takes place. South Africa. 6. Waiting Periods 4.1.108 “Transient ischemic attack (TIA)” is an acute episode of temporary neurological dysfunction caused by loss of blood flow in the brain, spinal cord, or eye or optic nerve or the sensory 6.1 Benefits are subject to a 3 (three) month Waiting Period from (vestibular) system that provides the sense of balance. Commencement Date unless stated otherwise. 4.1.109 “Urinalysis” is a urine test conducted by dipping a specialised 6.2 Pre-existing Conditions are subject to a 12 (twelve) month Waiting Period urinalysis stick into urine. from Commencement Date. 4.1.110 “Waiting Period” means the number of months from the 6.3 Please read through the Benefits carefully, as specific Waiting Periods are Commencement Date before the Members can access Benefits. specified under each Benefit. No claims will be payable during this period. 4.1.111 “Year” means a calendar year. 7
7. Benefits Centre. Includes treatment and Acute Medication dispensed by the Nurse practitioner according to the Formulary. 7.1 All Policy Benefits are payable up to the maximum cover limit as per Affinity Health’s Formulary, subject to the utilisation of an Affinity Health 7.5.2 Waiting Period Designated Service Provider (DSP). This Benefit is subject to a 1 (one) month Waiting Period from the Commencement Date. 7.2 All Benefits are subject to Pre-authorisation. 7.5.3 Special Conditions Day-to-Day Benefits 7.5.3.1 Only medication up to Schedule 4 can be dispensed by the Nurse practitioner at the centre. If this Option is selected, the following Benefits are payable subject to the Formulary: 7.5.3.2 The Assured Person(s) will be liable for payment of any procedures or medication not on the Formulary. 7.3 Nurse-led Medical Consultation Referrals 7.6 Primary Healthcare Screening 7.3.1 Defined Event Unlimited GP consultations when referred by a designated Nurse 7.6.1 Defined Event practitioner. Primary Healthcare Screening test, limited to 1 (one) collective screening visit per Member, per Year. Formulary tests are fully 7.3.2 Waiting Period covered when conducted by a Nurse practitioner at a This Benefit is subject to a 1 (one) month Waiting Period from the conveniently located Medical Society Centre. Commencement Date. 7.6.2 Waiting Period 7.4 Telehealth Consulting This Benefit has no Waiting Period and is applicable from the 7.4.1 Defined Event Commencement Date. Unlimited telephonic Nurse-led Medical Consultations with a 7.6.3 Special Conditions designated Nurse practitioner. Includes Acute Medication recommended by the Nurse practitioner according to the 7.6.3.1 Tests are limited to Blood Glucose Monitoring, Blood Formulary. Pressure Monitoring, Cholesterol Rapid Test, Urinalysis and Body Mass Index (BMI). 7.4.2 Waiting Period 7.6.3.2 Snellen Eye Tests, Pap Smears, and Audiometry are 7.4.2.1 This Benefit has no Waiting Period and is applicable available at selected centres only. from the Commencement Date. 7.6.3.3 Pap smears will be covered from the Pathology 7.4.2.2 Medication linked to this Benefit is subject to a 1 (one) Benefit provided the Member has obtained a referral month Waiting Period from the Commencement Date. from a GP or Specialist. 7.4.3 Special Conditions 7.6.3.4 HIV Rapid Tests and Pregnancy Tests are available in addition, charged as a cash service. 7.4.3.1 Medication authorised or prescribed will be covered according to the Formulary. 7.7 Doctor Consultations 7.4.3.2 Only medication up to Schedule 4 can be prescribed 7.7.1 Defined Event by the Nurse practitioner. Unlimited, managed, Network GP consultations subject to a 7.5 Nurse-led Medical Consultations maximum Rand value as per the Formulary. 7.5.1 Defined Event 7.7.2 Waiting Period Unlimited, managed, Nurse-led Medical Consultations with a This Benefit is subject to a 1 (one) month Waiting Period from the Nurse practitioner at a conveniently located Medical Society Commencement Date. 8
7.7.3 Special Conditions 7.10.2 Waiting Period 7.7.3.1 Pre-authorisation is required. This Benefit is subject to a 3 (three) month Waiting Period from the Commencement Date. 7.7.3.2 Assured Person(s) will be required to make use of a Network GP. 7.10.3 Special Conditions 7.10.3.1 Referral from a GP is required to claim this Benefit. 7.8 In-Room GP Procedures 7.10.3.2 Pre-authorisation is required. 7.8.1 Defined Event 7.11 Casualty Room Treatment Unlimited cover for minor procedures that can be performed in a 7.11.1 Defined Event GP’s rooms. The Emergency treatment of Medical Conditions and accidental 7.8.2 Waiting Period injuries in Casualty up to R3,500 per Policy per Year. This Benefit is subject to a 1 (one) month Waiting Period from the 7.11.2 Waiting Period Commencement Date. 7.11.2.1 In the event of an Accident, this Benefit has no Waiting 7.8.3 Special Conditions Period and is applicable from the Application Date. 7.8.3.1 Cover will be provided according to the Formulary. An 7.11.2.2 In the event of Illness, this Benefit is subject to a 1 exhaustive list of procedures is detailed in Schedule 1. (one) month Waiting Period from the Commencement Date. 7.8.3.2 Assured Persons will be required to make use of a Network GP. 7.11.3 Special Conditions 7.8.3.3 Pre-authorisation is required. 7.11.3.1 Casualty Treatment is subject to Pre-authorisation and/or approval by Affinity Health. 7.9 Out-of-Network GP Visits 7.11.3.2 The Emergency Treatment must meet the Clinical 7.9.1 Defined Event Guidelines and Managed Healthcare Protocols of Unlimited Out-of-Network visits. The Assured Person(s) will be Affinity Health. required to make an upfront payment and claim back from the 7.11.3.3 The Treatment is subject to Annual Benefit Limits and Assurer, up to the defined amount. the Member will be covered up to the Annual 7.9.2 Waiting Period Maximum Expenditure Limit according to the Member’s Policy Type. This Benefit is subject to a 1 (one) month Waiting Period from the Commencement Date. 7.11.3.4 Emergency Casualty Room Treatment as a result of an Accident between the Application Date and the 7.9.3 Special Conditions Commencement Date is subject to 1 (one) event up to R1,000 per Policy. Reimbursement of these claims will 7.9.3.1 The Assured Person(s) will be entitled to a only be done after collection of the first successful reimbursement amount of up to R250. premium. 7.9.3.2 Pre-authorisation is required. 7.11.3.5 In the event of this Benefit being claimed before the Commencement Date, the claim value will be 7.10 Specialist Visits deducted from the annual Benefit amount. 7.10.1 Defined Event 7.12 Trauma Support Services Up to R1,700 per single Member Policy per Year or R3,500 per 7.12.1 Defined Event Family Policy per Year Access to Affinity Health’s Trauma Support line 24 hours a day for 9
telephonic trauma support and counselling by qualified and 7.15 Radiology dedicated professionals. This includes the following events: sexual assault; crime, either during or after the crime event; 7.15.1 Defined Event trauma related to gender-based violence; death, natural or unnatural; attempted suicide; and domestic violence. Unlimited cover for basic Radiology. 7.12.2 Waiting Period 7.15.2 Waiting Period This Benefit has no Waiting Period and is applicable from the This Benefit is subject to a 1 (one) month Waiting Period from the Commencement Date. Commencement Date. 7.12.3 Special Conditions 7.15.3 Special Conditions This is a telephonic counselling service and medication will not be 7.15.3.1 A referral from a medical practitioner is required to covered under this Benefit. claim this Benefit. 7.13 Acute Medication 7.15.3.2 Only basic x-rays will be covered subject to the Affinity Health Radiology Formulary. 7.13.1 Defined Event 7.15.3.3 Radiology related to an Accident will be covered under Acute Medication linked to a GP consultation and either the Accident Benefit, if applicable to the chosen prescribed or dispensed by the GP will be covered. Option and subject to Benefit limits. 7.13.2 Waiting Period 7.16 Pathology This Benefit is subject to a 1 (one) month Waiting Period from the 7.16.1 Defined Event Commencement Date. Unlimited cover for basic Pathology. 7.13.3 Special Conditions 7.16.2 Waiting Period 7.13.3.1 Medication will be covered subject to the Formulary. This Benefit is subject to a 1 (one) month Waiting Period from the 7.13.3.2 Assured Persons are responsible for payment of Commencement Date. medication outside of the Formulary. 7.16.3 Special Conditions 7.13.3.3 Medication scripted by a Dispensing Provider will not be covered. 7.16.3.1 A referral from a medical practitioner is required to claim this Benefit. 7.13.3.4 Only medication scripted by a Network Medical Practitioner will be covered. 7.16.3.2 Basic Pathology will be covered subject to the Affinity Health Pathology Formulary. 7.14 Over-the-counter Medication 7.17 Dentistry 7.14.1 Defined Event 7.17.1 Defined Event Over-the-counter Medication up to R500 per single Member Policy or R1,000 per Family Policy per Year. Basic Dentistry cover including 1 (one) full mouth assessment and 1 (one) scale and polish every 6 (six) months. Infection control, 2 7.14.2 Waiting Period (two) intraoral radiographs, 3 (three) extractions and 3 (three) fillings per Assured Person(s) per Year. This Benefit is subject to a 1 (one) month Waiting Period from the Commencement Date. 7.17.2 Waiting Period 7.14.3 Special Conditions This Benefit is subject to a 3 (three) month Waiting Period from the Commencement Date. Only medication Pre-authorised by a Nurse Practitioner will be covered. 10
7.17.3 Special Conditions 7.20 Maternity Management Programme 7.17.3.1 Assured Person(s) will be required to make use of an 7.20.1 Defined Event Affinity Health Network Dentist. 7.20.1.1 Support for expectant mothers through the provision 7.17.3.2 Cover will be provided in accordance with the of medical advice and monitoring pregnancy through Formulary and Benefit Limits. to birth and up to six weeks post-delivery. 7.17.3.3 Cover will only be provided for posterior fillings. 7.20.1.2 Unlimited access to a Nurse practitioner for telephonic maternity advice. 7.17.3.4 Pre-authorisation is required. 7.20.2 Waiting Period 7.18 Optometry 7.20.2.1 This Benefit is subject to a 3 (three) month Waiting 7.18.1 Defined Event Period from the Commencement Date. 1 (one) eye test and 1 (one) set of standard frames and lenses per 7.20.2.2 Pre-Existing Conditions are subject to a 12 (twelve) Assured Person(s) per 24 (twenty-four) months. month Waiting Period from the Commencement Date. 7.18.2 Waiting Period 7.20.3 Special Conditions This Benefit is subject to a 12 (twelve) month Waiting Period from 7.20.3.1 Hospitalisation is not available to Members on the the Commencement Date. Day-to-Day Plan. 7.18.3 Special Conditions 7.20.3.2 Members may be referred to an Affinity Health 7.18.3.1 Assured Person(s) will be required to make use of Network GP. Spec- Savers. 7.20.3.3 Members may utilise the Specialist Benefit up to the 7.18.3.2 Cover will be provided in accordance with the Affinity maximum limits of R1,700 per single Member Policy Health Optometry Formulary. or R3,500 per Family Policy per Year. 7.18.3.3 No cover is provided for contact lenses, cosmetic 7.21 Post-Hospital Private Home Nursing finishes, sunglasses and LASIK surgery. 7.21.1 Defined Event 7.18.3.4 Cover for visits to an Ophthalmologist covered subject Up to R10,000 per single Member Policy and R12,000 per Family to Specialist Benefit sub limit as per 7.10. Policy per Year for the assistance of a private nurse following a stay in a Hospital, subject to 7.21.3. 7.19 Maternity Scans 7.21.2 Waiting Period 7.19.1 Defined Event This Benefit has no Waiting Period and is applicable from the 2 (two) growth sonars referred by a network GP, subject to the Commencement Date. Formulary. 7.21.3 Special Conditions 7.19.2 Waiting Period 7.21.3.1 This Benefit is only available where the Assured 7.19.2.1 This Benefit is subject to a 3 (three) month Waiting Person(s) is unable to perform 3 (three) or more Period from the Commencement Date. activities of daily living, listed below, as a result of 7.19.2.2 Pre-existing Conditions are subject to a 12 (twelve) Illness or accidental injury, without the help of month Waiting Period from the Commencement Date. another person, but with the use of appropriate assistive or corrective aids and appliances. 7.19.3 Special Conditions • Washing: The ability to wash in a bath or shower Scans are only available during the first and second trimester of (including getting into and out of a bath or pregnancy. shower). 11
• Dressing: The ability to put on, take off, secure within the first 2 (two) months following the first date and unfasten all garments. of application up to commencement date. Reimbursement of these claims will only be done • Feeding: The ability to cut meat, butter bread and after collection of the first successful premium. to get food and drink into the mouth using fingers or utensils. 7.22.3.2 No cover will be provided for Microtrauma injuries and Pathological Fractures under this Benefit. • Toileting: The ability to use the lavatory and to recognise the need to clear the bladder or bowel. 7.22.3.3 Dental treatment as a result of an Accident is limited to R20,000 per Policy per Year. • Mobility: The ability to move indoors from room to room on level surfaces. 7.22.3.4 Up to R10,000 per event for treatment in a Casualty Room as a result of an Accident. • Transferring: The ability to move from a bed to a chair or wheelchair and vice versa. 7.23 Motor Vehicle Accident Benefit - Road Accident Fund • Communicating: The ability to answer the 7.23.1 Defined Event telephone and take a message. Assistance is offered with claiming from the Road Accident Fund. 7.21.3.2 This must be confirmed in a report from a medical Affinity Health has a network of Attorneys that will assess the practitioner and an examination by a Medical Accident at no cost to the Member and will facilitate any Professional appointed by the Assurer. reimbursement from the Road Accident Fund on behalf of the Member. 7.21.3.3 The maximum Post-Hospital Private Home Nursing Benefit available, will be R15,000 in the lifetime of the 7.23.2 Waiting Period Policy. This Benefit has no Waiting Period and is applicable from the 7.21.3.4 Pre-authorisation is required. Application Date. 7.24 Major Trauma Hospital Benefits 7.24.1 Defined Event If this Option is selected, the following Benefits are payable subject to the Up to R500,000 per Member per event. Formulary: All of the below Benefits require Pre-authorisation. 7.24.2 Waiting Period This Benefit has no Waiting Period and is applicable from the 7.22 Accident Cover Commencement Date. 7.22.1 Defined Event 7.24.3 Special Conditions Cover in the event of an Accident as defined in Section 4 above. Up to R175,000 per single Member per event or R275,000 per 7.24.3.1 The injury must meet the definition of Major Trauma Family per event. in section 4 above, and is limited to treatment of the following: 7.22.2 Waiting Period • near drowning; This Benefit has no Waiting Period and is applicable from the Application Date. • internal and/or external head injuries; 7.22.3 Special Conditions • gunshot wounds; 7.22.3.1 Hospitalisation as a result of an Accident between the • loss of a limb(s); Application Date and the Commencement Date is subject to 1 (one) Admission per Policy for Emergency • Polytrauma (severe injuries to at least 2 or more Treatment, up to R100,000 per single Member Policy body systems endangering the life of the injured and R150,000 per Family Policy. This is only available person); 12
• severe burns (third and/or fourth degree across 7.26 24-Hour Emergency more than 10% of the body surface); 7.26.1 Defined Event • Paraplegia (loss of all motor and sensory function below the level of the injury); 24/7 emergency medical advice, ambulance services, inter- hospital transfers, Hospital Pre-authorisation and arranging for • Quadriplegia (loss of all motor and sensory guarantee of payment to the treating facility. function below the level of injury). 7.26.2 Waiting Period 7.24.3.2 Treatment required after Hospital discharge is limited to R100,000 per Member per event, subject to the 7.26.2.1 If claimed as a result of an Accident, this Benefit has maximum Benefit amount. no Waiting Period and is applicable from the Application Date. 7.24.3.3 This Benefit is subject to a limit of R1,100,000 per Policy. 7.26.2.2 If claimed as a result of Illness, this Benefit has no Waiting Period and is applicable from the 7.24.3.4 Upon payment of 100% of the Benefit amount, this Commencement Date. Benefit will be terminated and cannot be reinstated. 7.27 Trauma Support Services 7.24.3.5 Any planned procedures that are authorised in the first 12 months of the Membership, will carry a 20% 7.27.1 Defined Event Co-payment. Access to Affinity Health’s Trauma Support line 24 hours a day for 7.25 Casualty Room Treatment telephonic trauma support and counselling by qualified and dedicated professionals. This includes the following events: 7.25.1 Defined Event sexual assault; crime, either during or after the crime event; trauma related to gender-based violence; death, natural or The Emergency treatment of Medical Conditions and Accidental unnatural; attempted suicide; and domestic violence. Injuries in Casualty up to R3,000 per Policy per Year. 7.27.2 Waiting Period 7.25.2 Waiting Period This Benefit has no Waiting Period and is applicable from the 7.25.2.1 In the event of an Accident, this Benefit has no Commencement Date. Waiting Period and is applicable from the Commencement Date. 7.27.3 Special Conditions 7.25.2.2 In the event of Illness, this Benefit is subject to a 1 This is a telephonic counselling service and medication will not be (one) month Waiting Period from the Commencement covered under this Benefit. Date. 7.28 Daily Illness Hospitalisation 7.25.3 Special Conditions 7.28.1 Defined Event 7.25.3.1 The Emergency treatment must meet the Clinical When hospitalised due to Illness, the following amounts will be Guidelines and Managed Healthcare Protocols of payable for plans sold from 2019: Affinity Health. 1st Day 2nd Day 3rd Day 4th Day 5th Day 7.25.3.2 The treatment is subject to Annual Benefit Limits and the Member will be covered up to the Annual Up to Up to Up to Maximum Expenditure Limit according to the R22,000 / R22,000 / R22,000 / Up to Up to Member’s Policy Type. R27,000* R27,000* R27,000* R8,500 R8,500 R24,000* R24,000* R24,000* thereafter up to R3,000 per day up to a maximum of 21 days per Member, per Illness event. *Cover applicable when admitted to ICU and combined with the ICU Booster. 13
7.28.2 Defined Event administrative assistance and keeping the Member updated on the progress of the claim. When hospitalised due to illness, the following amounts will be payable for plans sold before 2019 (unless upgraded separately): 7.29.2 Waiting Period 1st Day 2nd Day 3rd Day 4th Day 5th Day This Benefit has no Waiting Period and is applicable from the Commencement Date. Up to Up to Up to Up to Up to R15,000 / R15,000 / R15,000 / R4,250 / R4,250 / 7.29.3 Special Conditions R17,500* R17,500* R17,500* R12,500* R12,500* thereafter up to R1,500 per day up to a maximum of 21 days per 7.29.3.1 Pre-authorisation is required to ensure that Members Member, per Illness event. * Cover applicable when admitted to are directed to a Network Provider. ICU and combined with the ICU Booster. 7.29.3.2 No claims will be covered if the claims are made more 7.28.3 Waiting Period than 12 (twelve) months after the Accident, death or diagnosis of disease. 7.28.3.1 This Benefit has a 3 (three) month Waiting Period from the Commencement Date. 7.29.3.3 All requested documentation must be submitted to Affinity Health to process the claim on the Member’s 7.28.3.2 There is a 12 (twelve) month Waiting Period for Pre- behalf. existing Conditions. 7.29.3.4 The Compensation Commission approves Benefits 7.28.4 Special Conditions subject to the Compensation of Occupational Injuries and Diseases Act. 7.28.4.1 Maximum Benefit limit is up to R131,000 per event for plans sold from 2019. 7.29.3.5 Claiming from the Compensation Commissioner is not possible if Members are self-employed (unless 7.28.4.2 Maximum Benefit limit is up to R77,500 per event for registered with the Compensation Commissioner). plans sold before 2019 that have not been upgraded separately. 7.30 Diagnostic Procedures 7.28.4.3 If The Assured Person(s) is admitted into Hospital 7.30.1 Defined Event within a 6 (six) month period for the same or a related Illness, the Benefit amount payable will recommence Up to R20,000 per single Member Policy and up to R25,000 per from the last day of the previous Admission. Family Policy per Year. 7.28.4.4 Assured Persons may be required to make use of a 7.30.2 Waiting Period Day Clinic or Day Hospital if instructed to do so by the 7.30.2.1 This Benefit is subject to a 3 (three) month Waiting Assurer. Period from the Commencement Date. 7.28.4.5 Only 2 (two) Admission claims per Assured Person(s) 7.30.2.2 There is a 12 (twelve) month Waiting Period for Pre- per Year will be payable. existing Conditions. 7.28.4.6 The treatment must meet the Clinical Guidelines and 7.30.3 Special Conditions Managed Healthcare Protocols of Affinity Health. 7.30.3.1 Assured Persons will be required to make an upfront 7.28.4.7 Any planned procedures that are authorised in the Co-payment as detailed in Schedule 2. first 12 months of the Membership, will carry a 20% Co-payment. 7.30.3.2 This Benefit will be subject to sub-limits as detailed in Schedule 2. 7.29 Workmen's Compensation Benefit 7.30.3.3 Upon completion of the Waiting Period, this Benefit 7.29.1 Defined Event will accumulate at R1,000 per month. The full Benefit This Benefit offers cover for occupational related injuries or amount will become available from the 13th diseases, in accordance with the plan type. Affinity Health also (thirteenth) month of cover. offers third party recovery services, such as advice and 14
7.30.3.4 Procedures as detailed in Schedule 2 will be covered 7.32.2 Waiting Period under the Diagnostic Benefit whether the Member is admitted in hospital, or treated as an out-of-hospital This Benefit is subject to a 12 (twelve) month Waiting Period from patient. the Commencement Date. 7.30.3.5 A GP or Specialist referral is required. 7.32.3 Special Conditions 7.31 Day Clinic / Day Hospital Procedures 7.32.3.1 Affinity will cover the costs of a registered Midwife in the Network with a valid practice number only. 7.31.1 Defined Event 7.32.3.2 The cost of hiring a birthing pool will be covered from Up to R25,000 per Member per Year for procedures conducted at the Natural Maternity Benefit. a Day Clinic/Day Hospital. 7.32.3.3 Only 1 (one) claim per Assured Person(s) per 12 7.31.2 Waiting Period (twelve) month period will be payable. 7.31.2.1 This Benefit is subject to a 3 (three) month Waiting 7.32.3.4 Birth before 35 (thirty-five) weeks of gestation will only Period from the Commencement Date. be covered in a Public Hospital. 7.31.2.2 There is a 12 (twelve) month Waiting Period for Pre- 7.32.3.5 Elective C-Section, where the C-Section has been existing Conditions determined to not be medically necessary, carries a 20% Co-Payment. 7.31.3 Special Conditions 7.33 Serious Illness Hospital Benefit 7.31.3.1 Assured persons will be required to make use of an affiliated Day Clinic. 7.33.1 Defined Event 7.31.3.2 Cover will be provided for procedures detailed in Should a Member be admitted for any of the Serious Illnesses Schedule 3. This list is not exhaustive and is defined in Section 4 above, authorised under the Hospital Illness dependent on the scope of the Day Clinic. Benefit, the Member will receive additional Benefits based on the diagnosis and treatment required as per the tables in Schedule 4 7.31.3.3 Treatment at a Day Clinic will be considered an of this Policy document. Admission claim under the Daily Illness Hospitalisation Benefit. Heart Attack, Heart Block, Stroke, and Cancer are seen as Serious Illnesses. 7.31.3.4 Dental treatment is limited to R10,000 per Member per Year. 7.33.1.1 Heart Attack 7.31.3.5 The treatment must meet the Clinical Guidelines and The Heart Attack must be confirmed, and the evidence needs to Managed Healthcare Protocols of Affinity Health. be submitted to qualify for this Benefit. The following evidence is required: 7.31.3.6 Any planned procedures that are authorised in the first 12 months of the Membership, will carry a 20% • A letter from the treating doctor to confirm the diagnosis and Co-Payment. symptoms of a typical chest pain or other symptoms typically associated with a Heart Attack. 7.32 Maternity Benefit • Electrocardiographic (ECG) changes indicative of a heart 7.32.1 Defined Event attack. The following stated Benefits are payable regardless of the • Elevation of the cardiac enzyme (CPK-MB) and Troponin T amount of Days spent in Hospital as an inpatient: blood test results above the generally accepted laboratory levels of normal. Procedure Amount Maternity (Natural, Home Birth and Water Birth) R25,000 7.33.1.2 Heart Block Maternity (C-Section) R35,000 The Heart Block must be confirmed to be a third degree heart block and the evidence needs to be submitted to qualify for this 15
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