COMPREHENSIVE MEDICAL AID PLAN

Extended benefit option with Self Managed Fund (SMF) facilities

Our comprehensive medical aid plan 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.

This benefit option is designed to provide additional day-to-day cover by way of a Self Managed Fund (SMF).

The plan includes substantial benefits for basic dentistry. This is an additional benefit covered by Genesis and not from your own pocket or SMF benefits.

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

Contributions 2021

Monthly Contributions PRIVATE COMPREHENSIVE
Adult R2,640
2 Adults R5,280
2 Adults + 1 Child R5,810
2 Adults + 2 Children R6,340
2 Adults + 3 Children R6,870

Benefits summary 2021

IN HOSPITAL COVER

PRIVATE COMPREHENSIVE
General practitioners and medical specialists

(including maternity benefits)

  • Cost up to 200% of Scheme Tariff
Ward fees
  • Cost up to 100% of Scheme Tariff
Psychiatric treatment
  • Benefits limited to PMB’s
  • Claims will be paid in full when obtained from a DSP
  • When treated in a non-DSP claims will be paid up to a 200% of Scheme Tariff when hospitalised, or the lower of cost of a R1,000 per contact out of hospital, further limited to R36,000 per beneficiary p.a.
Internal medical / surgical appliances & prosthetics
  • 100% of cost up to R30,000 per beneficiary p.a.
External medical / surgical appliances
  • 75% of cost up to R19,000 per member family p.a. when used for the treatment of fractures
  • Subject to approval
Pathology services
  • Cost up to 100% of Scheme Tariff
X-rays

(plain radiography)

  • 100% of the lower of cost or Scheme Tariff
MRI & CT scans
  • 100% of the lower of cost or Scheme Tariff
  • Subject to authorisation
  • Scans related to conservative treatment of back / neck conditions covered up to 50% of the lower of cost or Scheme Tariff, further limited to R7,600 per beneficiary p.a.
Pain relief
  • Epidural injection for conservative back and/or neck (spinal/vertebral) condition paid up to 75% of the cost, further limited to R5,000 per beneficiary per annum (all inclusive)
Physiotherapy

(must be directly related to reason for admission)

  • Cost up to 100% of Scheme Tariff
Maxillo-facial surgery
  • Cost up to 200% of Scheme Tariff
    Required as a result of major trauma or accident
    (excluding tooth implants, conservative dental treatment, fillings, X-rays, tooth extractions, root treatment, dentures, orthodontics, perio-dontal services and related costs)
  • Subject to authorisation
Dental

(part of “Basic dentistry” benefit)

  • Cost up to 100% of Scheme Tariff for the surgical removal of impacted wisdom teeth, limited to the lower of cost or R10,000 per case
  • Cost up to 100% of Scheme Tariff 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 R10,000 per case
  • Subject to Genesis protocols and approval
  • Limited to 1 hospital admission per beneficiary p.a.
Blood transfusion
  • Cost up to 100% of Scheme Tariff for material, apparatus and operator’s fees
Haemodialysis
  • 100% of cost up to R300,000 per member family p.a. at Scheme Tariff
Medicines used in hospital
  • 100% of legislated cost
Surgical procedures in doctors’ rooms
  • Cost up to 200% of Scheme Tariff for qualifying surgical procedures that would otherwise necessitate admission to a hospital
Breast reduction and augmentations
  • 100% of cost subject to available SMF balance
Cosmetic surgery

Including treatment for obesity & elective or planned procedures not directly caused by or related to illness, accident or disease.

  • 100% of cost subject to available SMF balance
Treatment relating to impotence
  • 100% of cost subject to available SMF balance
Statutory Prescribed Minimum Benefits (PMBs)
  • In private hospitals, benefits and limits as above
  • In public or state hospitals, benefits as prescribed by law

AUXILLARY SERVICES

PRIVATE COMPREHENSIVE
Endoscopy (diagnostic)
  • R5,750 per procedure for colonoscopy (all inclusive)
  • R3,650 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)

MAJOR MEDICAL ILLNESS COVER

Organ transplant
  • Cost of immunosuppressant medication up to R84,000 per member family p.a.
PRIVATE COMPREHENSIVE
Procedures and medication administered in and out-of-hospital for-
  • Annual limit of R550,000 per beneficiary up to 200% of Scheme Tariff 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 R250,000 per beneficiary p.a.
Hospice

Accommodation, Home care visits, Home visits by medical practitioner

  • 100% of cost
  • R200 per day
  • Cost up to 100% of Scheme Tariff

CHRONIC COVER (SUBJECT TO AUTHORISATION AND REGISTRATION)

PRIVATE COMPREHENSIVE
Prescribed chronic disease list conditions
  • Limited to the extent of the therapeutic algorithms
  • 100% of the cost of formulary drugs

OUT OF HOSPITAL

PRIVATE COMPREHENSIVE
Savings facility
  • No benefit
Self Managed Fund (SMF)
  • R8,160 per adult p.a.
  • Pro-rated and advanced quarterly
Medicines
  • 100% of legislated cost subject to available SMF balance
Prescription spectacle / contact lenses
  • 100% of cost subject to available SMF balance
  • Frames subject to R1,000 per beneficiary p.a. (included in SMF 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

  • Cost up to 200% of Scheme Tariff subject to available SMF balance
External surgical appliances and / or repair
  • 100% of cost subject to available SMF balance
Pathology services
  • Cost up to 200% of Scheme Tariff subject to available SMF balance
Plain Radiography (i.e. X-rays)
  • 50% Of the lower of cost or Scheme Tariff, limited to R5,000 per beneficiary p.a.
MRI and CT scans
  • 50% of the lower of cost or Scheme Tariff, limited to R7,600 per beneficiary p.a.
Basic dentistry

Covered at the lower of cost or Scheme Tariff for the following qualifying dental benefits (per beneficiary p.a.) when obtained from a registered Dental Practitioner:

  • Three (3) dental oral examinations
  • 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, bridges or dentures limited to the lower of cost or Scheme Tariff, further limited to R5,000
  • Surgical removal of impacted wisdom teeth, where pathology and pain are directly associated with wisdom teeth
  • One (1) scale and polish
  • One (1) dental implant limited to R10,000 per three year financial year cycle of membership.
Advanced dentistry

(i.e. orthodontic work)

  • 100% of cost subject to available SMF balance

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.

Scheme Tariff (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, however, payment is not guaranteed if clinical protocols and the terms and conditions as per the Scheme Rules are not met.
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 Scheme Tariff, 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 Scheme Tariff. 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 subject to PMB level of care”), then treatment must be obtained from any public or state hospital in South Africa and the Uniform Patient Fee Schedule (UPFS) tariff will apply. In addition, the Scheme’s Designated Service Providers (DSPs) in the Western Cape and Gauteng are public or state hospitals.

In short, PMB treatment in private hospitals is reimbursed in terms of the Rules where limits may apply. PMB treatment in public or state hospitals will be reimbursed subject to PMB level of care as prescribed in the Medical Schemes Act. This means that you will receive the same entitlement to treatment that applies to a public or state hospital patient as set out in the regulations to the Act. If in any doubt, please call our Call Centre for further information.

The cost of medical services rendered outside the Republic of South Africa, is excluded from the risk benefits on all options.

The cost of medical services rendered outside the Republic of South Africa, is excluded from the risk benefits on all options.

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 Comprehensive

English Afrikaans
Download handy Information Sheet regarding our 2021 Private Comprehensive option here Laai handige Inligtingsbrosjure oor die 2021 Private Comprehensive opsie hier af
Contributions

Contributions 2021

Monthly Contributions PRIVATE COMPREHENSIVE
Adult R2,640
2 Adults R5,280
2 Adults + 1 Child R5,810
2 Adults + 2 Children R6,340
2 Adults + 3 Children R6,870
Benefits

Benefits summary 2021

IN HOSPITAL COVER

PRIVATE COMPREHENSIVE
General practitioners and medical specialists

(including maternity benefits)

  • Cost up to 200% of Scheme Tariff
Ward fees
  • Cost up to 100% of Scheme Tariff
Psychiatric treatment
  • Benefits limited to PMB’s
  • Claims will be paid in full when obtained from a DSP
  • When treated in a non-DSP claims will be paid up to a 200% of Scheme Tariff when hospitalised, or the lower of cost of a R1,000 per contact out of hospital, further limited to R36,000 per beneficiary p.a.
Internal medical / surgical appliances & prosthetics
  • 100% of cost up to R30,000 per beneficiary p.a.
External medical / surgical appliances
  • 75% of cost up to R19,000 per member family p.a. when used for the treatment of fractures
  • Subject to approval
Pathology services
  • Cost up to 100% of Scheme Tariff
X-rays

(plain radiography)

  • 100% of the lower of cost or Scheme Tariff
MRI & CT scans
  • 100% of the lower of cost or Scheme Tariff
  • Subject to authorisation
  • Scans related to conservative treatment of back / neck conditions covered up to 50% of the lower of cost or Scheme Tariff, further limited to R7,600 per beneficiary p.a.
Pain relief
  • Epidural injection for conservative back and/or neck (spinal/vertebral) condition paid up to 75% of the cost, further limited to R5,000 per beneficiary per annum (all inclusive)
Physiotherapy

(must be directly related to reason for admission)

  • Cost up to 100% of Scheme Tariff
Maxillo-facial surgery
  • Cost up to 200% of Scheme Tariff
    Required as a result of major trauma or accident
    (excluding tooth implants, conservative dental treatment, fillings, X-rays, tooth extractions, root treatment, dentures, orthodontics, perio-dontal services and related costs)
  • Subject to authorisation
Dental

(part of “Basic dentistry” benefit)

  • Cost up to 100% of Scheme Tariff for the surgical removal of impacted wisdom teeth, limited to the lower of cost or R10,000 per case
  • Cost up to 100% of Scheme Tariff 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 R10,000 per case
  • Subject to Genesis protocols and approval
  • Limited to 1 hospital admission per beneficiary p.a.
Blood transfusion
  • Cost up to 100% of Scheme Tariff for material, apparatus and operator’s fees
Haemodialysis
  • 100% of cost up to R300,000 per member family p.a. at Scheme Tariff
Medicines used in hospital
  • 100% of legislated cost
Surgical procedures in doctors’ rooms
  • Cost up to 200% of Scheme Tariff for qualifying surgical procedures that would otherwise necessitate admission to a hospital
Breast reduction and augmentations
  • 100% of cost subject to available SMF balance
Cosmetic surgery

Including treatment for obesity & elective or planned procedures not directly caused by or related to illness, accident or disease.

  • 100% of cost subject to available SMF balance
Treatment relating to impotence
  • 100% of cost subject to available SMF balance
Statutory Prescribed Minimum Benefits (PMBs)
  • In private hospitals, benefits and limits as above
  • In public or state hospitals, benefits as prescribed by law

AUXILLARY SERVICES

PRIVATE COMPREHENSIVE
Endoscopy (diagnostic)
  • R5,750 per procedure for colonoscopy (all inclusive)
  • R3,650 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)

MAJOR MEDICAL ILLNESS COVER

Organ transplant
  • Cost of immunosuppressant medication up to R84,000 per member family p.a.
PRIVATE COMPREHENSIVE
Procedures and medication administered in and out-of-hospital for-
  • Annual limit of R550,000 per beneficiary up to 200% of Scheme Tariff 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 R250,000 per beneficiary p.a.
Hospice

Accommodation, Home care visits, Home visits by medical practitioner

  • 100% of cost
  • R200 per day
  • Cost up to 100% of Scheme Tariff

CHRONIC COVER (SUBJECT TO AUTHORISATION AND REGISTRATION)

PRIVATE COMPREHENSIVE
Prescribed chronic disease list conditions
  • Limited to the extent of the therapeutic algorithms
  • 100% of the cost of formulary drugs

OUT OF HOSPITAL

PRIVATE COMPREHENSIVE
Savings facility
  • No benefit
Self Managed Fund (SMF)
  • R8,160 per adult p.a.
  • Pro-rated and advanced quarterly
Medicines
  • 100% of legislated cost subject to available SMF balance
Prescription spectacle / contact lenses
  • 100% of cost subject to available SMF balance
  • Frames subject to R1,000 per beneficiary p.a. (included in SMF 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

  • Cost up to 200% of Scheme Tariff subject to available SMF balance
External surgical appliances and / or repair
  • 100% of cost subject to available SMF balance
Pathology services
  • Cost up to 200% of Scheme Tariff subject to available SMF balance
Plain Radiography (i.e. X-rays)
  • 50% Of the lower of cost or Scheme Tariff, limited to R5,000 per beneficiary p.a.
MRI and CT scans
  • 50% of the lower of cost or Scheme Tariff, limited to R7,600 per beneficiary p.a.
Basic dentistry

Covered at the lower of cost or Scheme Tariff for the following qualifying dental benefits (per beneficiary p.a.) when obtained from a registered Dental Practitioner:

  • Three (3) dental oral examinations
  • 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, bridges or dentures limited to the lower of cost or Scheme Tariff, further limited to R5,000
  • Surgical removal of impacted wisdom teeth, where pathology and pain are directly associated with wisdom teeth
  • One (1) scale and polish
  • One (1) dental implant limited to R10,000 per three year financial year cycle of membership.
Advanced dentistry

(i.e. orthodontic work)

  • 100% of cost subject to available SMF balance
Notes

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.

Scheme Tariff (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, however, payment is not guaranteed if clinical protocols and the terms and conditions as per the Scheme Rules are not met.
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 Scheme Tariff, 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 Scheme Tariff. 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 subject to PMB level of care”), then treatment must be obtained from any public or state hospital in South Africa and the Uniform Patient Fee Schedule (UPFS) tariff will apply. In addition, the Scheme’s Designated Service Providers (DSPs) in the Western Cape and Gauteng are public or state hospitals.

In short, PMB treatment in private hospitals is reimbursed in terms of the Rules where limits may apply. PMB treatment in public or state hospitals will be reimbursed subject to PMB level of care as prescribed in the Medical Schemes Act. This means that you will receive the same entitlement to treatment that applies to a public or state hospital patient as set out in the regulations to the Act. If in any doubt, please call our Call Centre for further information.

The cost of medical services rendered outside the Republic of South Africa, is excluded from the risk benefits on all options.

The cost of medical services rendered outside the Republic of South Africa, is excluded from the risk benefits on all options.

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.

Brochures

Private Comprehensive

English Afrikaans
Download handy Information Sheet regarding our 2021 Private Comprehensive option here Laai handige Inligtingsbrosjure oor die 2021 Private Comprehensive 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.

(*) 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.