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DISCOVERY HEALTH ESSENTIAL COMPREHENSIVE 2019

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Type of Medical Aid Plan: 
Threshold
Medical Aid Year: 
2019
Day to day Benefits: 

15% of your monthly contribution goes into your Medical Savings Account (MSA). Face-to-face and video GP consultations. MRI and CT scans We pay the first R2 900 from your day to-day benefits and the balance from your Hospital Benefit (for conservative back and neck scans, specific rules apply). Trauma Recovery Extender Benefit Extends your cover for out-of-hospital claims for recovery after certain traumatic events for the rest of the year in which the trauma took place, and a year after the trauma.

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

Any private hospital

Upfront Payments to hospitals: 

dental treatment Hospital Younger than 13 R2 400 13 and older R6 200 Day clinic Younger than 13 R1 100 13 and older R4 000

Specialists: 
Specialists we have a payment arrangement with Full cover Specialists we don’t have a payment arrangement with and 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): 
We pay the first R3 750 of the hospital account from your day-to-day benefits and 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.
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 900 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.
Prosthesis: 

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.

hip and knee joint A limit of R30 000 applies to each prosthesis for each admission.

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.

Medical and Surgical Appliances: 
(like wheelchairs, crutches and prostheses) R39 400 for your family Hearing aids R19 800 for your family
Maternity Confinements: 
You are covered for your delivery from the Hospital Benefit. In addition, you have private ward cover up to R1 970 per day for your approved hospital stay for the delivery.
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.
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: 

100% of the DHR

Specialist consultations: 

Specialists we have a payment arrangement with Up to the agreed rate
Specialists we don’t have a payment arrangement with 100% of the DHR

Optometry benefits: 
lenses, frames, contact lenses and surgery or any healthcare service to correct refractive errors of the eye R5 500 for each person
Basic dentistry: 
There is no overall limit for basic dental treatment. However, all dental appliances, their placement, and orthodontic treatment (including related accounts for orthognathic surgery) are paid at 100% of the Discovery Health Rate (DHR)
Radiology and Pathology: 
Subject to savings.
Pregnancy benefits: 
You are covered for12 consults 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.
Chronic Conditions
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

Total Contributions
Total Contribution Main Member: 
4509.00
Total Contribution Adult: 
4265.00
Total Contribution Child*: 
908.00
Essential Comprehensive
Annual Medical Savings Account
Annual Medical Savings Main Member: 
8112.00
Annual Medical Savings Adult: 
7668.00
Annual Medical Savings Child*: 
1632.00
Monthly Medical Savings
Savings Child*: 
136.00
Savings Adult: 
639.00
Savings Main Member: 
676.00
Annual Threshold Amounts
Annual Threshold Main Member: 
18800.00
Annual Threshold Adult: 
18800.00
Annual Threshold Child*: 
3600.00
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: 
3883.00
Risk Contribution Adult: 
3626.00
Risk Contribution Child: 
722.00
Medical Aid Plan Name Term: 
Any