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Discovery Health Essential Delta Comprehensive 2018

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Type of Medical Aid Plan: 
Threshold
Medical Aid Year: 
2018
Day to day Benefits: 

A high savings account and an UNLIMITED Above Threshold Benefit (ATB) for your day-to-day healthcare needs like GP consultation fees, radiology and pathology, eye care and dentistry. 15% of your monthly contribution goes into your Medical Savings Account. Some day-to-day healthcare services have limits. These limits apply to claims paid from your Medical Savings Account (MSA), Day-to-day Extender Benefit (DEB) (where applicable), claims paid from your pocket and Above Threshold Benefit. These are not separate benefits. You will have to pay for some healthcare expenses from your pocket before you reach your Annual Threshold. This is called the Self-payment Gap (SPG).

Co-payments: 
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy) R3 400. Dental admissions in hospital younger than 13 - R2 200, 13 and older - R5 650 Day clinic Younger than 13 - R1 000, 13 and older - R3 650, MRI & CT Scans in or out of hospital R2750
In Hospital Benefits
Are you prepared to use designated hospitals?: 
Yes
Hospital Rate of Payment: 
100% of Scheme Rate.
Hospitals: 

Private hospitals in the Delta Network.

Upfront Payments to hospitals: 

For planned admissions outside of the Delta Hospital Network, you must pay an upfront payment to the hospital of R7 650. Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy) R3 400. Dental admissions in hospital Younger than 13 - R2 200 13 and older - R5 650 Day clinic Younger than 13 - R1 000 13 and older - R3 650 MRI & CT Scans in or out of hospital R2 750

Casualty / Emergency Visits: 
Subject to savings.
Specialists: 
In our network, full cover. Not in our network 100% of the Discovery Health Rate.
Other healthcare professionals eg. Physio, Occupational, Dietician: 
In our network, full cover. Not in our network 100% of the Discovery Health Rate.
Radiology and pathology: 
100 % of Discovery Health Rate.
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
You must pay R3 400 upfront, we pay the balance of hospital account and related accounts from the Hospital Benefit. If done in the doctor’s rooms, we pay the account from your Hospital Benefit.
MRI and CT scans: 
If done as part of an approved admission, we pay up to 100% of DHR from the Hospital Benefit. If not related to your admission, we pay the first R2 750 from your savings. We pay the balance of the scan from the Hospital Benefit up to 100% of DHR.
ICU and High Care: 
100 % of Discovery Health Rate.
Dialysis: 
We cover these expenses in full if we have approved your treatment plan and you use a provider in our network. If you go elsewhere, we will pay up to 80% of the Discovery Health Rate.
Organ Transplants: 
As per Scheme Protocols.
Oncology / Cancer: 
We cover the first R400 000 of the approved cancer treatment in full, over a 12-month cycle. You will be required to pay 20% of the cost on all further treatment once costs for cancer treatment go over R400 000. Prescribed Minimum Benefits fully covered.
Neck and Back Operations: 
There is no overall limit if you get your prosthesis from our preferred suppliers. If you choose not to, a limit of R25 500 for the first level and R51 000 for two or more levels, limited to one procedure for each person each year.
Joint Replacements: 
There is no overall limit if you get your prosthesis from our preferred suppliers. If you choose not to, certain limits may apply to each prosthesis.
Prosthesis: 

Prosthetic devices used in spinal surgery. There is no overall limit if you get your prosthesis from our preferred suppliers. If you choose not to, a limit of R25 500 for the first level and R51 000 for two or more levels applies, limited to one procedure for each person each year. Shoulder joint prosthesis There is no overall limit if you get your prosthesis from our preferred suppliers. If you choose not to, a limit of R40 000 applies to each prosthesis. Major joints surgery We cover planned hip and knee joint replacements in full when you use a provider in our network. If you go elsewhere, we will pay up to 80% of the Discovery Health Rate the hospital account. A limit of R30 000 applies to each prosthesis for each admission. This network will not apply to emergency and trauma-related,surgeries.

Medical and Surgical Appliances: 
Subject to savings. R39 400 for your family. Hearing aids R19 000 for your family.
Maternity Confinements: 
100% of Discovery Health Rate. Private ward cover R1 880 per day for your approved delivery. You have cover of up to R5 000 for essential registered devices, for example breast pumps and smart thermometers. You are responsible for a 25% co-payment.
In Hospital Dentistry: 
Upfront payment. Balance of hospital account, dental surgeon & related accounts 100% DHR. Dental appliances & orthodontic treatment incl related accounts for orthognathic surgery we pay from your savings limited to R26 200 a person
Take home Medicine: 
Subject to savings.
Rehabilitation, Hospice and Step-down facilities: 
21 days for each person.
Treatment for Mental Health: 
21 days for admissions or up to 15 out-of-hospital consultations for each person for major affective disorders, anorexia and bulimia, and up to 12 out-of-hospital consultations for acute stress disorder accompanied by recent significant trauma.
HIV / AIDS: 
When you register for our HIVCare Programme, you are covered for the care you need, which includes additional cover for social workers. Be assured of confidentiality at all times. You need to get your medicine from a DSP to avoid a 20 % co-payment.
Ambulance Service: 
911
International Travel Benefit: 
Cover up to R5 million for each person on each journey for emergency medical costs while travelling outside of South Africa, for a period of 90 days from your departure from South Africa. Specific rules apply and pre-existing conditions are excluded.
Day-to-day benefits
GP consultations: 

Subject to savings.

Specialist consultations: 

Subject to savings.

Acute medicine: 

Subject to savings. Prescribed medicine (schedule 3 and above) Limits apply M - R18 600, M+1 - R22 600, M+2 - R27 200, M +3+ - R29 700

Over-the-counter (OTC) Medicine: 

Subject to savings. These claims do not add up to the Annual Threshold and are not paid from the Above Threshold Benefit.

Optometry benefits: 
Subject to savings. R5 000 for each person. Includes cover for lenses, frames, contact lenses and surgery or any healthcare service to correct refractive errors of the eye. Enjoy savings of 20% for frames and lenses at an optometrist in the network.
Basic dentistry: 
Subject to savings.
Specialised Dentistry: 
Subject to savings. Dental appliances and orthodontic treatment R26 200 for each person.
Orthodontics: 

Subject to savings. Dental appliances and orthodontic treatment R26 200 for each person.

MRI and CT Scans (Out of Hospital): 
We pay the first R2 750 of the scan from your savings. We pay the balance of the scan from the Hospital Benefit, up to 100% of the Discovery Health Rate.
Radiology and Pathology: 
Subject to savings.
Pregnancy benefits: 
You are covered for 12consults at your gynaecologist, GP or midwife. 1 NIPT screening, 2x 2D ultrasound scans, a defined basket of blood tests, 1 flu vaccination, 5 pre- or postnatal classes or consults with a registered nurse. Paid from Hospital Benefit.
Physiotherapy and Occupational Therapy day to day: 
Subject to savings. Limits apply M - R10 200, M+1 - R14 450, M+2 - R18 700, M+3+ - R22 100
Chronic Conditions
Provider: 
Designated Service Provider.
Chronic Conditions: 

You have cover for the 27 CDL conditions according to the Prescribed Minimum Benefits list and additional chronic conditions. Your condition needs to be approved for it to be covered. Chronic Disease List: Addison’s disease, asthma, bipolar mood disorder, bronchiectasis, cardiac failure, cardiomyopathy, chronic obstructive pulmonary disease, chronic renal disease, coronary artery disease, Crohn’s disease, diabetes insipidus, diabetes Type 1, diabetes Type 2, dysrhythmia, epilepsy, glaucoma, haemophilia, HIV, hyperlipidaemia, hypertension, hypothyroidism, multiple sclerosis, Parkinson’s disease, rheumatoid arthritis, schizophrenia, systemic lupus erythematosus, ulcerative colitis. Additional chronic conditions: Ankylosing spondylitis, Behςet’s disease, cystic fibrosis, delusional disorder, dermatopolymyositis, generalised anxiety disorder, Huntington’s disease, major depression, muscular dystrophy and other inherited myopathies, myasthenia gravis, obsessive compulsive disorder, osteoporosis, isolated growth hormone deficiency, motor neuron disease, Paget’s disease, panic disorder, polyarteritis nodosa, post-traumatic stress disorder, psoriatic arthritis, pulmonary intestinal fibrosis, Sjögren’s syndrome, systemic sclerosis, Wegener’s granulomatosis

Additional Chronic Conditions: 
Applicable - no medicine list apply
Preventative Care Benefits
Preventative Benefits: 

Covers certain tests at one of our wellness network providers, like blood glucose, blood pressure, cholesterol and body mass index. We also cover a mammogram every 2 years, Pap smear every 3 years, PSA (a prostate screening test) once a year and HIV screening tests. Seasonal flu vaccine during pregnancy, or for members 65 years or older and/or registered for certain chronic conditions. Additional, and/or more frequent screening is available for those who meet our clinical criteria. Kids screening covers growth assessment and health and milestone tracking at any one of our wellness network providers.

Total Contributions
Total Contribution Main Member: 
3694.00
Total Contribution Adult: 
3490.00
Total Contribution Child*: 
742.00
Essential Delta Comprehensive
Annual Medical Savings Account
Annual Medical Savings Main Member: 
6648.00
Annual Medical Savings Adult: 
6276.00
Annual Medical Savings Child*: 
1332.00
Monthly Medical Savings
Savings Child*: 
111.00
Savings Adult: 
523.00
Savings Main Member: 
554.00
Annual Threshold Amounts
Annual Threshold Main Member: 
16790.00
Annual Threshold Adult: 
16790.00
Annual Threshold Child*: 
3200.00
Above Threshold Benefit Limits
Above Threshold Benefit Main Member: 
9999999.00
Above Threshold Benefit Adult: 
9999999.00
Above Threshold Benefit Child*: 
9999999.00
Risk Contributions
Risk Contribution Main Member: 
3140.00
Risk Contribution Adult: 
2967.00
Risk Contribution Child: 
631.00
How many times per annum do you and your dependants visit a doctor?: 
40
How much do you spend on Acute medication per annum?: 
More than R 5000
How much do you spend on Chronic medication per annum?: 
More than R 5000
Will you or any of your dependants require specialised Dentistry: 
Yes