Pro-Care

Introduction

Pro-Care provides cover for people wishing to receive treatment in a private hospital. The product effectively gives the person cover up to a maximum of four times the Medical Aid tariff amount. That is, the Medical Aid covers the first 100% of the tariff amount and then Pro-Care Pro-Care Xtra and Pro-Care 100 covers the next 300%. Similarly, the Medical Aid covers the first 150%, 200% or 300% of the tariff amount and Pro-Care 150, 200 and 300 covers the next 250%, 200% and 100% respectively.Pro-Care is mainly for in-hospital treatment and procedures. Pro-Care Xtra includes an extra benefit to extend in-hospital sublimits for pathology, radiology and maternity by R2,500 per admission. The maximum age at entry is 65 years next birthday.

Benefits

The following example illustrates a typical Pro-Care 100 and Pro-Care 200 claim: HIP REPLACEMENT

Notes:

1. Co-payments are covered by the Elect-a-Care policy
2. Charged amount more than 4 times tariff

Conditions - no benefit is payable

• For out-patient treatment except those specified under benefits;
• In the event the insured did not pre-authorise, make use of a Designated Service Provider or any condition set by the insured's Medical Aid;
• If there is no benefit for treatment and / or condition or if it is excluded, by the insured's Medical Aid

Limits

• In-hospital treatment and certain specified out-of-hospital treatment.
• Pro-Care Xtra sublimit benefit is limited to R2,500 per admission payable at NHRPL (National Health Reference Price List)
• Annual limit of R500,000 per insured person.
• Annual limit of R1.5 million per family.

Waiting Periods

Should the policy start at the same time as the Medical Aid the policy shall apply the same waiting periods as the Medical Aid. All policies not starting at the same time as the Medical Aid will have a three month waiting period. There is a nine month waiting period on all maternity benefits.

Exclusions

The exclusions applied to this particular product are listed below. It is also important to note that all pre-existing conditions will be excluded unless accepted in writing by Turnberry.

1. Nuclear weapons or nuclear material or by ionising radiation or contimination by radioactivity from any nuclear waste from the combustion of nuclear fuel. For the purpose of this exception combustion shall include any self-sustaining process of nuclear fission;
2. Investigations, treatment or surgery for obesity its sequel or cosmetic surgery directly or indirectly caused by or related to or in consequence of cosmetic surgery other than as a result of an insured event otherwise insured. For the purpose of this exception cosmetic surgery shall include surgery for breast reduction or reconstruction unless necessitated as a result of treatment for cancer;
3. Routine physical examination or any laboratory test or procedure of a purely diagnostic nature e.g. x-rays and scans or any other examination where there are no objective indications of impairment in normal health except in the course of a disability established by prior call or attendance of a Medical Practioner;
4. Suicide, attempted suicide or intentional self-injury;
5. The taking of any drug or narcotic unless prescribed by and taken in accordance with the instructions of a Medical Practioner (other than the insured person) or drug addiction;
6. An event directly attributable to the insured person having an alcohol content exceeding the legal limit or the insured person suffering from alcoholism or any illness caused by the use of alcohol;
7. Participation in
   1. Active military duty, police duty, police reservist duty, civil commotion, labour disturbances, riot, strike or the activities of locked out workers;
   2. Aviation other than as a fare paying passenger;
   3. Any form of race or speed contest (other than on foot or involving any non-mechanically propelled vehicle, vessel, craft or aircraft);
8. All dental procedures, unless due to reconstructive surgery as a result of an accident;
9. Any claims in excess of the Principle Insured\\'s Medical Aid sub-limits, as specified by the Medical Aid except for the sublimit benefit on Pro-Care Xtra only;
10. The table of benefits applies in the territory of RSA and no benefits are payable for expenses incurred for transport charges or for services rendered whilst being transported in any emergency vehicle, vessel or aircraft;
11. No ward fee benefits shall be payable in respect of any additional costs incurred as a result of confinement to a private ward if such confinement to a private ward was requested by the insured person;
12. Investigations, treatment or surgery for maternity and childbirth during the first 9 months;
13. Investigations, treatment or surgery for artificial insemination or hormone treatment for infertility.

Premium Rates

Claims Procedure

1. Follow your medical aid's hospital pre-authorisation for hospital admission.
2. Turnberry musty be furnished with the following:
   1. Written notice of the claim within 6 months from the date of treatment for such incident;
   2. Supply in writing any such proof or other information as Turnberry may reasonably request, which would include your Medical Aid remittance advice and hospital and doctor's accounts providing the following information:
      1. The pre-authorisation number
      2. The ICD 10 code for the condition
      3. The procedure / tariff codes
3. Any benefit payable in respect of hospital confinement shall only become due at the end of a period of such confinement;
4. Any claims in terms of this policy will prescribe after 12 calendar months from the date of occurence of the insured incident if the claim is outstanding and not a subject of a then pending court case.

Disclaimer

The purpose of this product description is to provide a brief overview of Tunrberry's products. In the event of any dispute the terms and conditions as stated in the client's policy document issued by Turnberry shall prevail.