Are you prepared to use designated hospitals?:
Hospital Rate of Payment:
Unlimited private hospital cover in the Smart Hospital Network.
Upfront Payments to hospitals:
For planned admissions at hospitals outside of the Smart Hospital Network, you must pay an upfront payment of R8 800 to the hospital.
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy) You must pay the first R4 200 of the hospital account. The balance of the hospital account and related accounts will be paid from the Hospital Benefit.
Casualty / Emergency Visits:
We cover you in hospital for emergency hospital admissions.
Specialists:
Specialists we have a payment arrangement with, Full cover. Specialists we don’t have a payment arrangement with, 100% of the Discovery Health Rate (DHR).
Other healthcare professionals eg. Physio, Occupational, Dietician:
Other healthcare professionals, 100% of the Discovery Health Rate (DHR).
Radiology and pathology:
100% of the Discovery Health Rate (DHR).
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy):
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy) You must pay the first R4 200 of the hospital account. The balance of the hospital account and related accounts will be paid from the Hospital Benefit.
MRI and CT scans:
If related to your admission, we cover your scan up to 100% of the DHR from the Hospital Benefit, if not, we do not pay for it.
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 DHR.
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 are covered in
Joint Replacements:
Cover is limited to arthroscopies only.
In Hospital Dentistry:
The Severe Dental and Oral Surgery Benefit covers a defined list of procedures, with no upfront payment and no overall limit. Subject to authorisation and the Scheme’s rules.
Treatment for Mental Health:
21 days for admissions / 15 out-of-hospital consultations for each person for major affective disorders, anorexia and bulimia. 12 out-of-hospital consultations for acute stress disorder. 21 days for all other mental health admissions.
International Travel Benefit:
Cover for medical emergencies when travelling.
