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DISCOVERY HEALTH COASTAL CORE 2019

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Medical Aid Year: 
2019
In Hospital Benefits
Hospital Rate of Payment: 
Covered in full at the rate agreed with the hospital
Hospitals: 

On the Delta options, an upfront payment applies for admissions to hospitals outside
of the Delta Hospital Network. R7 650

Upfront Payments to hospitals: 

You need to pay an amount upfront to the hospital when one of the procedures listed below is performed during a hospital admission:

Conservative back and neck treatment,
adenoidectomy, myringotomy (grommets),
tonsillectomy

R3 350 Arthroscopy, functional nasal procedures,
hysterectomy (except for pre-operatively
diagnosed cancer), laparoscopy, hysteroscopy,
endometrial ablation

R7 950

Colonoscopy, sigmoidoscopy, proctoscopy,
gastroscopy, cystoscopy

R4 250 Nissen fundoplication (reflux surgery), spinal
surgery (back and neck), joint replacements

R16 350

Specialists: 
Specialists we have a payment arrangement with Full cover
Radiology and pathology: 
100% of the Discovery Health Rate (DHR)
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
You pay the first R4 550 of the hospital account and we pay the balance of the hospital account and related accounts from the Hospital Benefit. If done in the doctor’s rooms, you won’t have to pay an amount upfront. We pay the account from the Hospital Be
MRI and CT scans: 
related to your admission we pay up to 100% of the DHR from the Hospital Benefit. If not related to your admission or if for conservative back and neck treatment, we do not pay for it.
Prosthesis: 

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
applies for the first level and R51 000
for two or more levels, limited to one
procedure for each person each year.

 

Shoulder joint prostheses
There is no overall limit if you get your
prosthesis from our preferred suppliers.
If you choose not to, a limit of R41 700
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
DHR for 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.

Rehabilitation, Hospice and Step-down facilities: 
21 days for each person
Treatment for Mental Health: 
21 days for all other mental health admissions. All mental health admissions are covered in full at a network facility.
Day-to-day benefits
GP consultations: 

100% of the DHR

Specialist consultations: 

100% of the DHR

Over-the-counter (OTC) Medicine: 

75% of the DHR

MRI and CT Scans (Out of Hospital): 
If related to your admission, we pay 100% of the DHR from the Hospital Benefit. If not related to your admission or for conservative back and neck treatment, you have to pay the first R3 350 of the hospital account and we pay the first R2 900 of the scan
Pregnancy benefits: 
You are covered for up to eight consultations with your gynaecologist, GP or midwife.
Chronic Conditions
Chronic Conditions: 

You have cover for the 27 CDL conditions according to the Prescribed Minimum Benefits list. 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.

Total Contributions
Total Contribution Main Member: 
1770.00
Total Contribution Adult: 
1330.00
Total Contribution Child*: 
704.00
COASTAL CORE
Risk Contributions
Risk Contribution Main Member: 
1770.00
Risk Contribution Adult: 
1330.00
Risk Contribution Child: 
704.00
Medical Aid Plan Name Term: 
Any