Are you prepared to use designated hospitals?:
Hospital Rate of Payment:
Upfront Payments to hospitals:
You need to pay an amount upfront to the hospital when one of the in-hospital procedures listed below is performed during a hospital admission: R3 050 - A Conservative back and neck treatment, adenoidectomy, myringotomy (grommets), tonsillectomy. R3 900 - Colonoscopy, sigmoidoscopy, proctoscopy, gastroscopy, cystoscopy. R7 300 - Arthroscopy, functional nasal procedures, hysterectomy (except for pre-operatively diagnosed cancer), laparoscopy, hysteroscopy, endometrial ablation. R15 000 - Nissen fundoplication (reflux surgery), spinal surgery (back and neck), joint replacements. MRI & CT Scans in or out of hospital R2 750 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 If the procedure can be done out of hospital, for example in the doctor’s rooms, you won’t have to pay an amount upfront to the hospital. Please call us beforehand to confirm your benefits.
Casualty / Emergency Visits:
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 900 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.
Oncology / Cancer:
We cover the first R200 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 R200 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.
Medical and Surgical Appliances:
Subject to savings. R26 450 for your family. Hearing aids R13 500 for your family.
Maternity Confinements:
100 % of Discovery Health Rate.
In Hospital Dentistry:
Upfront payment. Balance of hospital account, dental surgeon & related accounts 100% of the DHR. Dental appliances & orthodontic treatment incl related accounts for orthognathic surgery we pay from your savings limited to R16 300 a person.
Rehabilitation, Hospice and Step-down facilities:
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.
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.
