Defined-Care

Introduction

The Defined-Care policy has been designed to provide a stated benefit that is paid depending on the condition for which hospitalisation is required, regardless of cost. We have approximately 300 conditions currently listed, examples of which are listed below. These conditions will be extended on an ongoing basis. Conditions requiring hospitalisation that are not listed will be linked to a condition of similar severity on the list and the appropriate benefit will be paid. The maximum age at entry is 65 years next birthday.

Benefits

Should the insured suffer a stroke a benefit of R7,500 would be paid, regardess of how much the service providers are charging or how much the Medical Aid pays. The benefit is paid directly to the insured, who can use the money to either settle any outstanding amount due or assist with future rehabilitation.

Limits

• Annual limit of R500,000 per insured person
• Annual limit of R1,500,000 per family

Table of Benefits - Examples

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. Depression, insanity, mental or stress-related conditions, chronic fatigue syndrome
6. 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;
7. 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;
8. 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.