Comprehensive
Medical Aid Plan

Extended benefit option including excellent in-hospital cover and generous day-to-day benefits by means of a Self Managed Fund (SMF).

Comprehensive
Medical Aid Plan

Extended benefit option including excellent in-hospital cover and generous day-to-day benefits by means of a Self Managed Fund (SMF).

Our Comprehensive Medical Plan Package

This plan is ideally suited for individuals/families who require in-hospital cover for planned and emergency hospital admissions, as well as generous day-to-day benefits by means of a Self Managed Fund. Includes some out-of-hospital cover for X-rays, MRI / CT scans and diagnostic endoscopy (i.e. colonoscopy & gastroscopy). Doctors and specialists are covered at 200% of the Scheme Tariff.

Also includes substantial benefits for basic dentistry –  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). *

Comprehensive Medical Aid

Comprehensive

MEDICAL AID PLAN

(including maternity benefits)

  • Cost up to 200% of Scheme Tariff
  • Cost up to 100% of Scheme Tariff
  • Benefits limited to PMBs
  • Claims will be paid in full when obtained from a DSP
  • When treated in a non-DSP claims will be paid up to 200% of Scheme Tariff when hospitalised, or the lower of cost or an R1,000 per contact out of the hospital, further limited to R36,000 per beneficiary p.a.
  • 100% of cost up to R30,000 per beneficiary p.a.
  • 75% of cost up to R19,000 per member family p.a. when used for the treatment of fractures
  • Subject to approval
  • Cost up to 100% of Scheme Tariff

(plain radiography)

  • 100% of the lower of cost or Scheme Tariff
  • 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.
  • 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)

(must be directly related to the reason for admission)

  • Cost up to 100% of Scheme Tariff
  • 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

(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.
  • Cost up to 100% of Scheme Tariff for material, apparatus and operator’s fees
  • 100% of cost up to R300,000 per member family p.a. at Scheme Tariff
  • 100% of legislated cost
  • Cost up to 200% of Scheme Tariff for qualifying surgical procedures that would otherwise necessitate admission to a hospital
  • 100% of cost subject to available SMF balance

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
  • 100% of cost subject to available SMF balance
  • In private hospitals, benefits and limits as above
  • In public or state hospitals, benefits as prescribed by law

  • R5,750 per procedure for colonoscopy (all inclusive)
  • R3,650 per procedure for gastroscopy (all inclusive)

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

  • Oncologist consultations, chemotherapy, radiotherapy (including brachytherapy), MRI / CT / PET and bone scans, pathology tests, medication and materials up to R250,000 per beneficiary p.a.
  • Cost of immunosuppressant medication up to R84,000 per member family p.a.

Accommodation, Homecare visits, Home visits by a medical practitioner

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

  • Limited to the extent of the therapeutic algorithms
  • 100% of the cost of formulary drugs

  • No benefit
  • R8,160 per adult p.a.
  • Pro-rated and advanced quarterly
  • 100% of legislated cost subject to available SMF balance
  • 100% of cost subject to available SMF balance
  • Frames subject to R1,000 per beneficiary p.a. (included in SMF 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
  • 100% of cost subject to available SMF balance
  • Cost up to 200% of Scheme Tariff subject to available SMF balance
  • 50% of the lower cost or Scheme Tariff, limited to R5,000 per beneficiary p.a.
  • 50% of the lower cost or Scheme Tariff, limited to R7,600 per beneficiary p.a.

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 is limited to R10,000 per three-year financial year cycle of membership.

(i.e. orthodontic work)

  • 100% of cost subject to available SMF balance

Comprehensive Medical Aid

Important 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 the Scheme Tariff, depending on 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, Northern 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 of the Act.

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.

We are the SMART choice

Premium benefits

We are the SMART choice

We are the peoples choice

We are the people's choice​

lowest membership increases

Known for lowest increases​

Choose your trusted doctor or hospital

Choose your trusted doctors/hospital

What our Members say...

Genesis Medical, I highly recommend you to everyone I meet… Why? … There are no words to say thank you enough for being there for my family and I during all these years. Not only have all my bills been paid without issue, but you as a medical scheme have taught me to negotiate with doctors and with hospitals so that my funds are looked after and last longer and we remain in charge. There are no surprise unpaid accounts once procedures or emergencies are done, you let us know in advance how to negotiate and what is not covered. Every emergency, you have given us peace of mind when we are sick, knowing you have us covered on all fronts.

You have a business that is run on focusing on your members and it shows. You give us that special personal touch. I can call anytime of day and someone friendly answers and helps me immediately. There is no passing the buck with you.

If I ever had a problem, within minutes, it was solved. Thank you for being the first to live up to no frills… just cover… when you need it most.

MOST important is that your increases are so ealistic and amazing, you really care about your members. You understand that living is hard, and you make it easy to stay with you. Service, staff, benefits – everything is excellent….. No one compares to you as a whole. You tick every box … and that is hard to find in a medical aid these days.

Kind regards, The Truter family

Anuske Truter

Mother / Genesis member

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.

A bit overwhelmed? Let's clear things up and give you peace of mind

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You don’t have to make use of any network hospitals or doctors. As a member of Genesis, you have the freedom to choose any private hospital in South Africa. You may also be treated by any doctor or specialist that is registered by the Health Professions Council of South Africa.

It is important to note, however, that the use of private providers (even for PMBs), may have limits on the reimbursement of doctors.

Genesis covers all approved conditions, including Prescribed Minimum Benefits (PMBs), in private hospitals, where the benefits and limits, as set out in the Rules, apply. Hospital accounts, including treatment for PMBs, 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, even for PMBs, will be reimbursed at 100% or 200% of the 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, Genesis has Designated Service Provider (DSP) agreements with the Western Cape, Northern Cape and Gauteng Departments of Health.

View the full list of DSPs in the Western Cape, Northern Cape and Gauteng.

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.

Bear in mind that this does not mean that you must or can only be treated in a public sector hospital. PMB treatment in public hospitals simply protects Genesis and its members from health service providers who charge excessively for their services when the condition is a PMB. The choice, however, remains yours.

Waiting periods are not always imposed when joining Genesis. It is done at the Scheme’s discretion after assessing the health profile of the applicant and is used as a measure to prevent people from joining the Scheme purely because they have to go to the hospital in the near future. There are two kinds of waiting periods, i.e.:

  • A general waiting period of up to three months – during this period, members have to pay their normal monthly contributions, but are not entitled to claim any benefits whatsoever, except in certain instances with claims relating to PMBs and in which instance the treatment and/or service have to be obtained from any public or state hospital in South Africa and the Uniform Patient Fee Schedule (UPFS) tariff will apply.
  • The condition-specific waiting period of up to 12 months – during this period, members have to pay their normal monthly contributions, but any pre-existing health condition(s) will be excluded and all medical costs associated during the first 12 months will be for the member’s own pocket, except in certain instances with claims relating to PMBs and in which instance the treatment and/or service have to be obtained from any public or state hospital in South Africa and the Uniform Patient Fee Schedule (UPFS) tariff will apply.

Genesis may apply premium penalties to applicants who have not been a member(s) of a recognised South African medical scheme after the age of 35. Read up more on the late joiner penalty

The MMI benefit (for the treatment of cancer, stroke, motor-neuron disease and organ transplant(s)) is designed to provide cover for expenses that are both in and out of the hospital, or post-operative. The MMI benefit on the Private and Private Comprehensive options has an overall limit of R550 000 per beneficiary per annum, with sub-limits for certain treatment protocols.

The in-hospital MMI benefit on the Private Choice option is are limited to R50 000 per beneficiary per annum. Out-of-hospital MMI benefits on the Private Choice option is further limited to statutory Prescribed Minimum Benefits (PMBs).

Should membership be subject to a 3-month general waiting period and the member has access to Prescribed Minimum Benefits (PMBs), these benefits will only be available from a public/state facility. Should you have specific questions about this benefit, please contact Genesis directly.

No.  All approved conditions are covered in terms of the benefits and limits as set out in the Scheme Rules.  Where service providers charge more than the Scheme Tariff, you may have a co-payment(s).

Genesis covers all approved conditions, including Prescribed Minimum Benefits (PMBs), in private hospitals, where the benefits and limits, as set out in the Rules, apply. Hospital accounts, including treatment for PMBs, 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, even for PMBs, will be reimbursed at 100% or 200% of the Scheme Tariff, depending on 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 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.

Unless expressly stated to the contrary, members on the Private Comprehensive benefit option may use their SMF benefit to pay for their and / or their registered dependants’ day-to-day medical expenses.

At the beginning of each three months period in any financial year, the Scheme will make available a SMF benefit not exceeding three times the monthly SMF contribution that is included in your monthly contribution.  In addition, any amount unused from a previous three month period in the same financial year, will be added to your available SMF balance.

The SMF benefit of those members joining the Scheme during a financial year, will be prorated to the end of the applicable three month period of that financial year.

At the end of each financial year, any unused balance in the SMF will be forfeit to the Scheme after first settling any qualifying expenditure, relating to treatment / service rendered in the particular year, submitted to the Scheme within four (4) months after that particular financial year end.