Introduction

A number of clients either do not have money to cover the co-payments specified by their Medical Aid option or they want to ensure that when they go into hospital most of the costs are covered including those in excess of their Medical Aid sublimits. Elect-a-Care is designed to pay thye co-payments or compulsory deductibles and costs in excess of sublimits on Medical Aid options. The maximum age at entry is 65 years next birthday.

Benefits

Elect-a-Care covers the cost of in-hospital co-payments and costs in excess of in-hopital sublimites and specified out-patient sublimits (namely chemotherapy, radiology, dianostic radiology and kidney dialysis) up to a maximum of R10 000 per admission.

Conditions - no benefit is payable

  • If the Overall Annual Limit for hospitalisation is exceeded;
  • 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 the treatment and / or condition or if it is excluded, by the insured's Medical Aid

Limits

  • Co-payments and costs in excess of sublimits are limited to a maximum of R10,000 per admission
  • Benefits payable at NHRPL (National Health Reference Price List)
  • Annual limit of R200,000 per insured person.
  • Annual limit of R1,000,000 per family.

Waiting Periods

  • There is a 3 month waiting period on all policies
  • There is a 9 month waiting period on all maternity benefits
  • There is a 12 month waiting period for a hysterectomy

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. 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;
  3. Suicide, attempted suicide or intentional self-injury;
  4. 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;
  5. 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;
  6. 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);
  7. Investigations, treatment or surgery for maternity and childbirth during the first 9 months and hysterectomy during the first 12 months of the policy;
  8. Investigations, treatment or surgery for obesity, it's sequelae or cosmetic surgery or 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;
  9. Investigations, treatment or surgery for artificial insemination or hormone treatment for infertility;
  10. Investigations, treatment or surgery for dentistry other than maxillo-facial surgery;
  11. Depression, insanity, mental or mental stress-related conditions.

Premium Rates

Elect-a-Care               R100   

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.