Maxi-Care

Introduction

Maxi-Care is an appropriate policy for all Medical Aids at apply an annual overall limit for in-hospital treatment. Should you develop a serious health condition or be involved in a bad accident you are likely to have very high medical bills which may not be classified as a Prescribed Minimum Benefit (PMB) and could exceed your Medical Aid's overall annual limit for in-hospital treatment. The product has two options to select from, namely to increase your overall annual limit by R1,750,000 or R3,500,000. The maximum age at entry is 65 years next birthday.

Benefits

The benefits of Maxi-Care are best illustrated by an actual claim where costs were high and incurred over a lengthy period of time, as detailed below.

A client joined the Medical Aid and Maxi-Care halfway through the year. His Medical Aid's overall annual limit was pro-rated to give him R90,400 in-hospital cover under his Medical Aid for that year. On 27 December of that same year he was involved in an accident and requiered hospitalisation, emergency surgery and was placed in ICU. The total cost for treatment between 27 and 31 December was R120,500. The client remained in ICU for most of January and his Medical Aid 's overall annual limit  was used up mid-February. He was hospitalised until the end of May, during which time he received rehabilitation treatment to learn to walk again. There was an additional R481,200 in costs incurred once his annual overall Medical Aid limit was reached.

What would have happened if the client did not have Maxi-Care? The client would have had to finance the costs himself. If he was unable to finance the costs, he would have been forced to leave the hospital early and not received the rehabilitation treatment required, and in all probability would never have walked again.

During the period from the commencement of the policy to the date of discharge from hospital this client paid a total of R900 in premiums and received a benefit from Maxi-Care of R511,300. The Personal Finance section of the Saturday Star, 11 April 2009, sights an example of an extreme case of costs amounting to R6million.

Limits

• In-hospital treatment and certain out-of-hospital treatment.
• Maxi-Care pays for hospitalisation if the overall annual limit of the medical aid has been reached, but not if sub-limits on the medical aid have been reached.
• Annual limit of R1,750,000 for the standard Maxi-Care policy per family.
• Annual limit of R3,500,000 for the extended Maxi-Care policy per family.

Waiting Periods

Should the policy stat 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 conseqauence of cosmetic surgery other than as a result of an insured event otherwise insured. For the purpose of this exception cosmetic suregery 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);

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.