COMPREHENSIVE MEDICAL AID PLANS

Extended plans with medical savings & other day-to-day benefits

Our comprehensive medical aid 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 plans are also designed to provide additional day-to-day cover by way of a medical savings account, as well as separate cover for consultations (at any practitioner registered with the Health Professions Council of South Africa) and medication on the Private Comprehensive option.

Both comprehensive 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 or medical savings account.

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

Members can choose between two full cover medical aid plan benefit options, namely the Private Plus and the Private Comprehensive options.


 

  • Contributions 2016

    Monthly Contributions PRIVATE PLUS PRIVATE COMPREHENSIVE
    Adult R1800 R2 150
    2 Adult R3 600 R4 300
    2 Adult + 1 Child R3 950 R4 650
    2 Adult + 2 Children R4 225 R4 925
    2 Adult + 3 Children R4 500 R5 200
  • Benefits summary 2016

    IN HOSPITAL COVER

    Service / Treatment PRIVATE PLUS PRIVATE COMPREHENSIVE
    General practitioners and medical specialists(including maternity benefits)
    • Cost up to 200% 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 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.
    • 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
    • 100% of cost up to R30 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
    • 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.
    • 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 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
    • 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
    • 100% of cost up to R300 000 per member family p.a. at Medical Aid Rate
    • 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 200% 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
    • 100% of cost subject to available savings balance
    • 100% of cost subject to available savings balance
    Cosmetic surgery, including treatment for obesity and elective procedures
    • 100% of cost subject to available savings balance
    • 100% of cost subject to available savings balance
    Treatment relating to impotence
    • 100% of cost subject to available savings balance
    • 100% of cost subject to available savings balance
    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 PLUS PRIVATE COMPREHENSIVE
    Endoscopy (diagnostic)
    • R 3 750 per procedure for colonoscopy (all inclusive)
    • R2 500 per procedure for gastroscopy (all inclusive)
    • 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 PLUS PRIVATE COMPREHENSIVE
    Procedures and medication administered in and out-of-hospital for-
    • 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

    • 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.
    • 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.
    • 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.
    • 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

     

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

    CHRONIC COVER (SUBJECT TO AUTHORISATION AND REGISTRATION)

    Service / Treatment PRIVATE PLUS PRIVATE COMPREHENSIVE
    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 PLUS PRIVATE COMPREHENSIVE
    Savings facility
    • R3 960 per adult p.a.
    • R2 520 per adult p.a.
    Medicines
    • 100% of legislated cost subject to available savings balance
    • 100% of legislated cost limited to R3 600 per adult p.a.
    • Balance subject to available savings balance
    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 Medical Aid Rate subject to available savings balance
    • Four (4) consultations per adult p.a. with any healthcare provider registered with the Health Professions Council of SA, subject to a maximum amount of the lesser of cost or R350 per consultation
    • Balance paid at 200% of Medical Aid Rate subject to available savings balance
    Spectacles and contact lenses
    • 100% of cost subject to available savings balance
    • 100% of cost subject to available savings balance
    External surgical appliances and / or repair
    • 100% of cost subject to available savings balance
    • 100% of cost subject to available savings balance
    Radiology (i.e. X-rays) and pathology services
    • Cost up to 200% of Medical Aid Rate subject to available savings balance
    • Cost up to 200% of Medical Aid Rate subject to available savings balance
    MRI and CT scans
    • 50% of the lower of cost or Medical Aid Rate, limited to R6 000 per beneficiary p.a.
    • 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)
    • 100% of cost subject to available savings balance
    • 100% of cost subject to available savings 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.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 Plus

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

    Private Comprehensive

      Download handy Information Sheet regarding our 2016 Private Comprehensive option here
      Laai handige Inligtingsbrosjure oor die Private 2016 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.