2022 Policy Document JUNIOR

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2022 Policy Document JUNIOR
JUNIOR
Policy Document
2022

Simple, cost-effective and
reliable health insurance.
2022 Policy Document JUNIOR
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.
2022 Policy Document JUNIOR
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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