Comprehensive Medical Cover

comprehensive medical aid cover

When selecting a medical scheme benefit option, one of the most important considerations is the level of in-hospital (risk) cover you are buying.

Hospital plan cover vs comprehensive medical cover

Factors such as unlimited hospitalisation vs capped / limited cover, reimbursement of claims at 100% or 200% of the medical scheme rate and freedom of choice vs the limitation of network hospitals or doctors are all important factors to consider.

Whilst a good hospital plan, generally speaking, could provide the best value for money with the right mix of cover, many people still prefer a benefit option that provides comprehensive medical cover.  That is, in-hospital benefits, as well as out-of-hospital (day-to-day) benefits.

Private Comprehensive benefits 2020  –  overview

The Private Comprehensive benefit option on Genesis Medical Scheme offers exceptional value for money.

Unless specifically stated to the contrary, there is no overall annual limit for hospital cover and members may use any private hospital and doctor or medical specialist in South Africa.*

The Private Comprehensive benefit option will cover members in hospitals for planned and emergency hospital admissions.  It will also provide cover for related accounts, such as theatre costs, X-rays, scans, pathology, physiotherapy, blood transfusion, medicines, etc.  Further benefits include generous basic dentistry benefits.

Whilst in hospital, the Scheme will reimburse General Practitioners and Specialists at cost up to 200% of Medical Aid Rate.

Day-to-day cover for out-of-hospital medical expenses will be covered by benefits available in the member’s Self Managed Fund (SMF).  Each adult beneficiary will receive a SMF benefit of R8,160 p.a., which will be pro-rated and advanced quarterly.  This benefit may be shared by all beneficiaries.

In essence, medical scheme cover on the Private Comprehensive benefit option consists of three elements, namely:

  1. In-hospital benefits
  2. Out-of-hospital benefits
  3. Basic dentistry benefits


Unless specifically stated to the contrary in the Rules, there is no overall limit for hospital cover.  The Scheme will pay for all qualifying medical conditions.  In-hospital cover includes theatre costs, as well as treatment in the Intensive Care Unit (ICU), High Care Unit or a general ward in any private hospital in South Africa.

In-hospital benefits include (but are not limited to) the benefits as listed below.  Note that sub-limits may be available on stated benefits.

  • Unlimited Specialist treatment
  • Unlimited General Practitioner treatment
  • Internal & external prosthesis (stated benefits)
  • X-rays
  • Certain MRI / CT scans
  • Pathology (e.g. blood   tests)
  • Medication
  • Emergency pre-hospital treatment & transport (ER24)
  • Physiotherapy
  • Colonoscopies &  Gastroscopies (stated benefits)
  • Blood transfusions
  • Maxillo-facial surgery   related to trauma / accident
  • Surgical removal of bony impacted wisdom teeth, where pathology and pain are directly associated with  the wisdom teeth (benefit up to R10,000 per case)
  • Extractions & fillings for children < 9 years   (benefit up to R10,000;   once-only, life-time  benefit)
  • Major medical illness cover for cancer, stroke, motor neuron disease & organ transplant (stated benefits)
  • Maternity benefits
  • Neonatal ICU
  • Mental health (stated benefit)
  • Cosmetic surgery, treatment relating to impotence or treatment for obesity (subject to available SMF balance)
  • Other elective procedures (subject to available SMF balance)


The following benefits are available, subject to the funds available in the member’s SMF and provided that the healthcare practitioner is registered with the Health Professions Council of South Africa:

  • GP / Specialist consultations
  • Prescribed & over the counter medication
  • Optometrists, spectacles & contact lenses
  • Psychologists
  • Physiotherapy / Biokinetcis
  • X-rays
  • Pathology (e.g. blood   tests)
  • Speech therapy / Audiology
  • External appliances (e.g. hearing aids)
  • Dietetic services
  • Advanced dentistry (e.g. orthodontic work, dentures)
  • Maternity benefits (e.g. antenatal visits, pregnancy scans)
  • Chiropractic services
  • Occupational therapists
  • Social workers
  • Preventative care (e.g. baby immunisations, flu vaccines)
  • Preventative screening tests (e.g. pap smear, mammogram)
  • Homeopaths and related services

Out-of-hospital MRI & CT scan benefits are also available.  Genesis will cover 50% of the lower of cost or Medical Aid Rate, limited to R7,250 per beneficiary per annum.


Generous basic dentistry benefits are available to each beneficiary and include the benefits / services listed below, when obtained from a registered Dental Practitioner.

Basic dentistry benefits form part of the member’s risk benefits and, provided that the Dental Practitioner charges Medical Aid Rates, the member should not have to fund these benefits from their available SMF balance, or own pocket.  Note that sub-limits are applicable on certain benefits.

  • Three (3) dental oral examinations p.a
  • Six (6) fillings p.a
  • Unlimited tooth extractions
  • Six (6) X-rays for conservative dentistry p.a. (excluding wide angle / panorex imaging and MRI / CT scans)
  • Two (2) root canal treatments p.a. (excluding wisdom teeth)
  • Crowns, dentures or bridges limited to the lower of cost or Medical Aid Rate, further limited to R3,850 p.a
  • Surgical removal of bony impacted wisdom teeth, where pathology and pain are directly associated with the wisdom teeth (benefit up to R10,000 per case)
  • In-hospital extractions & fillings for children < 9 years (benefit up to R10,000; once-only, life-time benefit)


  • Doctors’ and Specialists’ fees are paid at cost up to 200% of Medical Aid Rate.
  • All other benefits are paid at cost up to 100% of Medical Aid Rate.
  • Sub-limits on certain procedures may apply.
  • Hospital admissions and MRI & CT scans need pre-approval from the Scheme.
  • For further information, please contact Genesis Medical Scheme on 0860 10 20 10.

*Terms & Conditions apply as set out in the Scheme Rules. Prescribed Minimum Benefits (PMBs) in private hospitals are covered in terms of the Scheme Rules. Benefits in public or state hospitals are covered as prescribed by law.

Feel free to have a look at our Contact Us page to view our Genesis Medical Aid contact number

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