Hospital Rate of Payment:
Covered in full at the rate agreed with the hospital
Upfront Payments to hospitals:
Scopes: You must pay the first R4 550 of the hospital account. The balance of the hospital account and related accounts will be paid from the Hospital Benefit. If done in the doctor’s rooms, you won’t have to pay an amount upfront. If performed outside of the day surgery network an upfront payment of R8 800 will apply.
MRI and CT scans: If not related to your admission or if for conservative back and neck treatment, you will have to pay the first R2 900 and the balance will be paid from the Hospital Benefit.
Specialists:
Specialists we have a payment arrangement with Full cover Specialists we don’t have a payment arrangement with and other healthcare professionals 200% of the Discovery Health Rate (DHR)
Other healthcare professionals eg. Physio, Occupational, Dietician:
200% of the Discovery Health Rate (DHR)
Radiology and pathology:
100% of the Discovery Health Rate (DHR)
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy):
You must pay the first R4 550 of the hospital account. The balance of the hospital account and related accounts will be paid 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 related to your admission, we cover your scan up to 100% of the DHR from the Hospital Benefit.
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
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 applies 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.
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.
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.
