WHICH PRODUCT SHOULD I CHOOSE?

I am on a registered medical aid and I want to be sure that if service providers charge above scheme tariff for authorised in-hospital procedures, including for oncology, then this shortfall will be covered up to the maximum percentage, regardless of the number of times per year this cover is needed.*
I am on a registered medical aid that may not provide full cover of Prescribed Minimum Benefits and I want this shortfall covered.*
I am on a registered medical aid and the option I’m on requires a member co-payment for certain procedures performed in-hospital. I want cover for this co-payment and will use my medical aid’s designated service provider network.*
I am on a registered medical aid and the option I’m on requires a member co-payment for certain procedures performed in-hospital. I want cover for this co-payment and WILL NOT use my medical aid’s designated service provider network.*
I am on a registered medical aid and the option I’m on has sub-limits for prostheses costs and MRI/CT/PET scans as part of the hospitalisation benefit. I want additional cover should these specific limits be reached.*

      
I am on a registered medical aid and I want to know that charges above an annual scheme limit on oncology treatment will be covered up to an additional R120 000.*

*All products are subject to an aggregate annual limit of R150 000 per insured person per annum. (This limit may be subject to regulatory amendment).


 


Premium per policy per month

- Individuals = R99
- Families = R150
- Over 65+ years (age of main
Insured - for individuals and/or
Families) = R300
- Individuals and/or families = R165
- over 65+ years (age of main
insured - for individuals
and/or families) = R250

- Individuals and/or families = R210
- Over 65+ years (age of main
insured - for individuals
and/or families) = R315

- Individuals and/or families = R345
- Over 65+ years (age of main
insured - for
individuals and/or families) = R415



 I HAVE A CLAIM! HOW DOES EACH OPTION COVER IT?


*GAP COVER OR ONCOLOGY
GAP COVER CLAIM:

• PMB’s or NON PMB’s
• IN NETWORK or OUT OF NETWORK


*CASUALTY UNIT CLAIM







*CO–PAYMENT CLAIM:

• PMB’s or NON PMB’s
• IN NETWORK




*CO–PAYMENT CLAIM:

• PMB’s or NON PMB’s
• OUT OF NETWORK




*SUB-LIMIT COVER CLAIM

• (MRI/CT/PET SCANS OR
PROSTHESES ONLY)



 
*ONCOLOGY EXTENDER CLAIM







Errors and Omissions Excepted. Terms and Conditions apply. This infographic does not constitute advice. Consult your intermediary for advice regarding product choice. The products reflected above are not medical aids. They are not the same as medical aids. They are not substitutes for medical aids. TRA (Total Risk Administrators Pty Ltd) is an authorised financial services provider | FSP No 40815. Products underwritten by Auto & General Insurance Company Limited - Registration No 1973/016880/06 I FSP No 16354.



DEFINITIONS

PRESCRIBED MINIMUM BENEFITS
A set of defined benefits, as per the Medical Schemes Act, in terms of which all medical schemes have to cover the costs related to the diagnosis, treatment and care of: any emergency medical condition; a limited set of 270 medical conditions; and 27 chronic conditions.

EMERGENCY MEDICAL CONDITION
An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.

GAP COVER AND / OR ONCOLOGY GAP COVER CLAIM
A claim for the shortfall that arises after your medical aid has processed your account and is due to service providers charging above scheme tariff for authorised in-hospital procedures.

CASUALTY UNIT CLAIM
• A claim for costs related to treatment received while in a hospital casualty unit.
• The treatment is related to an emergency, immediately required, is of an external nature or came about due to an external force and/or impact with something or someone.
• Your medical aid has processed this account and paid their share of the claim, even if this amount is zero.

CO-PAYMENT CLAIM
• A claim for the upfront co-payment or deductible that your medical aid charges you for certain in- hospital procedures.
• This co-payment or deductible is NOT related to the scheme tariff and service provider charge shortfall OR designated service provider arrangements or any penalties charged.

SUB-LIMIT CLAIM
A claim for the shortfall on a service provider account that is not covered because you have reached a sub-limit for Prostheses, MRI / CT / PET Scans imposed by your medical aid and this is directly related to an authorised hospitalisation event.

IN NETWORK
Use of your medical aid’s designated provider network for hospitalisation. This normally results in the member not paying anything out of their own pocket.

OUT OF NETWORK
The voluntary use of providers that are not part of your medical aid’s designated provider network for hospitalisation. This may result in the member having to pay additional amounts out of their own pockets.