•   New Members:
    0861 56 46 66
  •   Existing Members:
    0860 10 20 10
  •   Hospital Admissions:
    0860 10 62 05
healthcare benefits

HOSPITAL PLANS

Rated best hospital plan in South Africa*

Our hospital plans will cover you in hospital for planned and emergency hospital admissions. While your focus should be on getting better, we will provide you with the welcome peace of mind that your hospital and related accounts will be taken care of.

Both hospital plans include substantial benefits for basic dentistry (R25 000 per beneficiary per annum). This is an additional benefit covered by Genesis and not from your own pocket.

You may use any private hospital and doctor or medical specialist in South Africa (no networks).**

Members can choose between two hospital plan benefit options, namely the Private Choice and the Private benefit options.


 

  • Contributions 2016

    Monthly Contributions PRIVATE CHOICE PRIVATE
    Adult R950 R1 420
    2 Adult R1 900 R2 840
    2 Adult + 1 Child R2 220 R3 190
    2 Adult + 2 Children R2 470 R3 465
    2 Adult + 3 Children R2 720 R3 740
  • Benefits summary 2016

    IN HOSPITAL COVER

    Service / Treatment PRIVATE CHOICE PRIVATE
    General practitioners and medical specialists(including maternity benefits)
    • Cost up to 100% of Medical Aid Rate
    • Cost up to 200% of Medical Aid Rate
    Ward fees
    • Cost up to 100% of Medical Aid Rate
    • Cost up to 100% of Medical Aid Rate
    Psychiatric treatment
    • Cost up to 100% of Medical Aid Rate
    • 3 days per beneficiary p.a. in hospital & 18 days per beneficiary p.a. in a health establishment registered in terms of section 5 of the Mental Healthcare Act, 2002
    • Limited to R36 000 per beneficiary p.a.
    • Cost up to 200% of Medical Aid Rate
    • 3 days per beneficiary p.a. in hospital & 18 days per beneficiary p.a. in a health establishment registered in terms of section 5 of the Mental Healthcare Act, 2002
    • Limited to R36 000 per beneficiary p.a.
    Internal medical / surgical appliances
    • 50% of cost up to R20 000 per member family p.a.
    • 100% of cost up to R30 000 per member family p.a.
    External medical / surgical appliances
    • 75% of cost up to R16 500 per member family p.a. when used for the treatment of fractures
    • Subject to approval
    • 75% of cost up to R16 500 per member family p.a. when used for the treatment of fractures
    • Subject to approval
    Pathology services
    • Cost up to 100% of Medical Aid Rate
    • Cost up to 100% of Medical Aid Rate
    X-rays (plain radiography)
    • 100% of the lower of cost or Medical Aid Rate
    • 100% of the lower of cost or Medical Aid Rate
    MRI & CT scans
    • 100% of the lower of cost or Medical Aid Rate
    • Subject to authorisation
    • Member has a co-payment of R2 750 per scan
    • Up to two (2) scans per member family p.a., further limited to R6 250 per scan
    • Dento-alveor procedures and conservative treatment of back / neck conditions excluded
    • 100% of the lower of cost or Medical Aid Rate
    • Subject to authorisation
    • Scans related to conservative treatment of back / neck conditions covered up to 50% of the lower of cost or Medical Aid Rate, further limited to R6 000 per beneficiary p.a.
    Physiotherapy (must be directly related to reason for admission)
    • Cost up to 100% of Medical Aid Rate
    • Cost up to 100% of Medical Aid Rate
    Maxillo-facial surgery
    • Cost up to 100% of Medical Aid Rate
    • Required as a result of major trauma or accident (excluding tooth implants, conservative dental treatment, fillings, root treatment, dentures, orthodontics, perio-dontal services, x-rays, tooth extractions and related costs)
    • Subject to authorisation
    • Cost up to 200% of Medical Aid Rate
    • Required as a result of major trauma or accident (excluding tooth implants, conservative dental treatment, fillings, root treatment, dentures, orthodontics, perio-dontal services, x-rays, tooth extractions and related costs)
    • Subject to authorisation
    Dental (part of “Basic dentistry” benefit)
    • Cost up to 100% of Medical Aid Rate for the surgical removal of impacted wisdom teeth, limited to the lower of cost or R9 000 per case
    • Cost up to 100% of Medical Aid Rate for child beneficiaries, prior to attaining the age of 9 years, for extractions and fillings (once only, lifetime limit), limited to the lower of cost or R9 000 per case
    • Subject to Genesis protocols and approval
    • Limited to 1 hospital admission per beneficiary p.a.
    • Cost up to 100% of Medical Aid Rate for the surgical removal of impacted wisdom teeth, limited to the lower of cost or R9 000 per case
    • Cost up to 100% of Medical Aid Rate for child beneficiaries, prior to attaining the age of 9 years, for extractions and fillings (once only, lifetime limit), limited to the lower of cost or R9 000 per case
    • Subject to Genesis protocols and approval
    • Limited to 1 hospital admission per beneficiary p.a.
    Blood transfusion
    • Cost up to 100% of Medical Aid Rate for material, apparatus and operator’s fees
    • Cost up to 100% of Medical Aid Rate for material, apparatus and operator’s fees
    Haemodialysis
    • No benefit
    • 100% of cost up to R300 000 per member family p.a. at Medical Aid Rate
    Medicines used in hospital
    • 100% of legislated cost
    • 100% of legislated cost
    Surgical procedures in doctors’ rooms
    • Cost up to 100% of Medical Aid Rate for qualifying surgical procedures that would otherwise necessitate admission to a hospital
    • Cost up to 200% of Medical Aid Rate for qualifying surgical procedures that would otherwise necessitate admission to a hospital
    Breast reduction and augmentations
    • No benefit
    • No benefit
    Cosmetic surgery, including treatment for obesity and elective procedures
    • No benefit
    • No benefit
    Treatment relating to impotence
    • No benefit
    • No benefit
    Statutory Prescribed Minimum Benefits (PMBs)
    • In private hospitals, benefits and limits as above
    • In public or state hospitals, benefits as prescribed by law
    • In private hospitals, benefits and limits as above
    • In public or state hospitals, benefits as prescribed by law

    AUXILLARY SERVICES

    Service / Treatment PRIVATE CHOICE PRIVATE
    Endoscopy (diagnostic)
    • No benefit
    • R 3 750 per procedure for colonoscopy (all inclusive)
    • R2 500 per procedure for gastroscopy (all inclusive)
    Emergency pre-hospital treatment, evacuation and transport, including inter- hospital transfers within RSA
    • 100% of cost when using the preferred provider (ER24)
    • 100% of cost when using the preferred provider (ER24)

    MAJOR MEDICAL ILLNESS COVER

    Service / Treatment PRIVATE CHOICE PRIVATE
    Procedures and medication administered in and out-of-hospital for-
    • Annual in-hospital limit of R50 000 per beneficiary up to 100% of Medical Aid Rate for cancer, stroke, motor-neuron disease and organ transplant
    • Out-of-hospital benefits limited to Statutory Prescribed Minimum Benefits (PMBs)
    • Annual limit of R550 000 per beneficiary up to 200% of Medical Aid Rate for cancer, stroke, motor-neuron disease and organ transplant

    FURTHER SUB-LIMITS APPLY FOR:

    Cancer
    •  
    • Oncologist consultations, chemotherapy, radio-therapy (including brachytherapy), MRI / CT / PET and bone scans, pathology tests and materials up to R210 000 per beneficiary p.a.
    Stroke
    •  
    • In-hospital rehabilitation up to R80 000 per member family p.a.
    Organ transplant
    •  
    • Cost of immunosuppressant medication up to R84 000 per member family p.a.

    Hospice

    • Accommodation
    • Home care visits
    • Home visits by medical practitioner
    •  

     

    • 100% of cost
    • R200 per day
    • Cost up to 100% of Medical Aid Rate

    CHRONIC COVER (SUBJECT TO AUTHORISATION AND REGISTRATION)

    Service / Treatment PRIVATE CHOICE PRIVATE
    Prescribed chronic disease list conditions
    • Limited to the extent of the therapeutic algorithms
    • 100% of the cost of formulary drugs
    • Limited to the extent of the therapeutic algorithms
    • 100% of the cost of formulary drugs

    OUT OF HOSPITAL

    Service / Treatment PRIVATE CHOICE PRIVATE
    Savings facility
    • No Benefit
    • No Benefit
    Medicines
    • No Benefit
    • No Benefit

    Consultation Benefit

    • General practitioners & medical specialists
    • Speech therapy & audiology
    • Chiropractic services
    • Dietician’s services
    • Psychologist
    • Social worker
    • Physiotherapy / Biokinetics
    • Optometrist
    • Alternative treatments
    • Homeopath & related services
    • No Benefit
    • No Benefit
    Spectacles and contact lenses
    • No Benefit
    • No Benefit
    External surgical appliances and / or repair
    • No Benefit
    • No Benefit
    Radiology (i.e. X-rays) and pathology services
    • No Benefit
    • No Benefit
    MRI and CT scans
    • No Benefit
    • 50% of the lower of cost or Medical Aid Rate, limited to R6 000 per beneficiary p.a.
    Basic dentistry
    • The lower of cost or Medical Aid Rate up to R25 000 per beneficiary p.a. for the following qualifying dental benefits when obtained from a registered Dental Practitioner
      • Three (3) dental consultations
      • Six (6) fillings
      • Tooth extractions
      • Six (6) plain X-rays for conservative dentistry (excluding wide angle / panorex imaging and CT / MRI scans)
      • Two (2) root canal treatments, excluding root canal treatment on wisdom teeth
      • Crowns, dentures or bridges limited to the lower of cost or Medical Aid Rate, further limited to R3 000
      • Surgical removal of impacted wisdom teeth, where pathology and pain are directly associated with wisdom teeth
    • The lower of cost or Medical Aid Rate up to R25 000 per beneficiary p.a. for the following qualifying dental benefits when obtained from a registered Dental Practitioner
      • Three (3) dental consultations
      • Six (6) fillings
      • Tooth extractions
      • Six (6) plain X-rays for conservative dentistry (excluding wide angle / panorex imaging and CT / MRI scans)
      • Two (2) root canal treatments, excluding root canal treatment on wisdom teeth
      • Crowns, dentures or bridges limited to the lower of cost or Medical Aid Rate, further limited to R3 000
      • Surgical removal of impacted wisdom teeth, where pathology and pain are directly associated with wisdom teeth
    Advanced dentistry (i.e. orthodontic work)
    • No Benefit
    • No Benefit
  • Benefits reflected in this schedule are for the full benefit year and will be pro-rated for those members joining Genesis during the benefit year.

    Medical Aid Rate (Genesis Rate)
    Means the fixed tariff determined by Genesis for the payment of relevant health services / benefits in accordance with the Rules of the Scheme, or the fee determined in terms of any agreement between the Scheme and a service provider(s) in respect of the payment of relevant health services.

    Benefits are subject to Genesis issuing a hospital admission reference number.

    Beneficiaries on all options share the benefits of adult members, unless expressly stated to the contrary. Prescribed Minimum Benefits (PMBs) cannot be limited beyond the limits prescribed by law. For further information contact Genesis.

    Genesis does not provide any kind of healthcare service or treatment. Treatment can only be provided by / in a registered healthcare practitioner(s) and / or institution(s). The function of the Scheme is therefore to provide the funding for such treatment and will accordingly reimburse members’ claims in terms of its Rules.

    Genesis covers all approved conditions, including Prescribed Minimum Benefits (“PMBs”), in private hospitals, where the benefits and limits, as set out in the Scheme Rules, apply. Hospital accounts will usually be paid in full in terms of tariff agreements with the hospital. In private hospitals, the charges of attending doctors / specialists and other healthcare service providers, will be reimbursed at 100% or 200% of Medical Aid Rate, depending which benefit option you are on.

    This funding applies to all claims for treatment in private hospitals, even if the condition is listed as a PMB. Shortfalls relating to treatment received in private hospitals usually pertain to charges for attending doctors / specialists if they charge more than 100% or 200% of the Medical Aid Rate. To this end, should your claim be listed as a PMB and you want it to be paid according to the law as provided for in section 29(1)(p) of the Medical Schemes Act (“paid in full”), then treatment may be obtained from any public or state hospital in South Africa and the Uniform Patient Fee Schedule (UPFS) tariff will apply. If in any doubt, please call the Call Centre for further information.

    The Scheme Rules, including a list of excluded conditions, procedures and services for all benefit options are available on the website or on request from the Scheme.

  • Private Choice

      Download handy Information Sheet regarding our 2016 Private Choice option here
      Laai handige Inligtingsbrosjure oor die 2016 Private Choice opsie hier af

    Private

      Download handy Information Sheet regarding our 2016 Private option here
      Laai handige Inligtingsbrosjure oor die 2016 Private opsie hier af


Whilst every effort has been made to ensure that the benefits set out herein comprise a detailed summary of the relevant Rules of Genesis, any dispute will be resolved by reference to the registered Rules of Genesis approved by the Registrar of Medical Schemes.
(*) Independent studies conducted by Towers Watson, the GTC Medical Aid Survey and AON Hewitt South Africa.
(**) Terms & conditions apply as per the Scheme Rules. Statutory Prescribed Minimum Benefits in private hospitals are covered as per the Scheme Rules. In public or state hospitals, benefits are as prescribed by law.