Scheme Exclusions



Unless otherwise expressly stated to the contrary in these Rules and the Annexures and Appendices or as otherwise determined by the Board, expenses incurred in respect of any of the following conditions, procedures and services shall not be covered by the Scheme.

Self Managed Fund (SMF) facilities, where applicable and to the extent available, may be used to cover expenses where indicated. Please also refer to the detailed benefit analysis of Annexure B where limitations are mentioned in conjunction with specific benefits.

Nothing in this Annexure C shall have the effect of limiting the Statutory Prescribed Minimum Benefits beyond the limits prescribed by law.

The following exclusions apply to all members and beneficiaries irrespective of benefit option:

  1. Travelling expenses other than (a) ambulance services as provided for in Rules 1.1.6 (c), 2.1.6 (c) and 3.1.5 (b) of Annexure B and, (b) service providers as provided in the Doctor’s Billing Manual.

  2. Services rendered by a dental technician not registered with the Dental Technicians Board as a dental technician.

  3. Holidays for recuperative purposes, whether deemed medically necessary or not.

  4. Costs for services rendered by any institution, except a state or provincial hospital, not registered in terms of any law.

  5. Accounts for appointments not kept by members or any dependants of a member.

  6. Costs of treatment, blood tests and operations relating to slimming whether performed by the slimming clinic or the medical practitioner or nurse.

  7. Medical treatment in a research environment and all drugs, medication, substances, appliances and the like that is experimental and/or not registered in terms of appropriately recognised law in the Republic of South Africa or any of the above that are authorised in terms of section 21 of the Medicines and Related Substances Control Act 101 of 1965 or the off-label use of any medical treatment.

  8. Educational, remedial or marriage counselling with a Clinical Psychologist or Social Worker.

  9. Purchase of:

    9.1 applicators, toiletries, beauty preparations, nappies and linen protectors;

    9.2 bandages, cotton wool and similar aids;

    9.3 patented foods, including baby foods;

    9.4 slimming preparations and drugs as advertised to the public;

    9.5 household and biochemical remedies;

    9.6 medication, injections and apparatus to induce and sustain erection.

  10. Costs for services rendered by –

    10.1 persons not registered with a recognised professional body constituted in terms of an Act of Parliament; or

    10.2 any institution, nursing home or similar institution, except a state or provincial hospital, not registered in terms of any law.

  11. Notwithstanding anything provided to the contrary in these rules, any medical condition or complication that arises at a later stage as a result of any originally excluded treatment or benefit or medication is similarly excluded from benefits.

  12. In the event of any other party (including a manufacturer or supplier) being liable, whether in part or in full, for the cost incurred for the recall, replacement or repair of any defective product used or device/implant inserted in respect of a member or his/her dependant, the Scheme shall be entitled to be reimbursed or may recover from the other party concerned or the member, if payment has been made to the member by the other party concerned, the full cost of the product used or cost associated with the initial insertion of the device/implant (including the cost of any diagnostic, work-up and follow-up interventions) incurred by the Scheme, provided that the quantum of the reimbursement/recovery may not exceed what was actually paid for by the Scheme in respect of such product, device or implant.

  13. Except for PMBs, benefits arising out of the following:

    13.1 rehabilitation.

  14. The cost of medical services rendered outside the Republic of South Africa.

  15. In cases of illness a protracted nature, the Scheme may require a second opinion in respect of proposed treatment or medicine and shall have the right to insist that a member or dependant of a member consult any particular medical or dental expert specialist the Scheme may nominate, at the cost of the Scheme, in consultation with the attending practitioner. In the event that the second opinion proposes different treatment or medicine to the first, the Scheme may in its discretion require that the second opinion proposals be followed.

    Members on the MED-200 Plus benefit option may use any available balance in their SMF for the following conditions that are otherwise excluded from benefits for all benefit options:

  16. Except for the PMBs, all costs for operations, medicines, treatment and procedures for cosmetic purposes or elective procedures. This includes, but is not limited to:

    16.1 radial keratotomy, excimer laser, phakic implants, cochlear implants, blepharoplasty;

    16.2 total or sub-total cosmetic reconstruction of the nose, cosmetic rhinoplasty;

    16.3 genioplasty;

    16.4 otoplasty;

    16.5 abdominoplasty; abdominal lipectomy;

    16.6 breast augmentation and breast reductions;

    16.7 gastric by-pass surgery for obesity;

    16.8 revision of scars and keloids;

    16.9 fertility procedures, in vitro fertilisation or GIFT procedure;

    16.10 hyperbaric oxygen therapy;

    16.11 hypnotherapy, narcoanalysis, sleep therapy;

    16.12 collagen implantation;

    16.13 oral hygiene instructions by a dental practitioner;

    16.14 any other surgery performed at the same time as any procedure listed herein and not directly caused by, attributable to or related to illness, accident or disease.

  17. Except for PMBs all costs related to any treatment or procedure relating to infertility or the artificial insemination of a person as defined in the Human Tissues Act, 1983 (Act 65 of 1983) and the treatment of erectile dysfunction and loss of libido.

  18. Costs for accommodation and frail care and old age homes and other geriatric institutions including frail care and assistance in the home environment other than as provided for in Rules 1.1.6(f), 1.2.2, 2.1.6(f) and 2.2.2 of Annexure B.

  19. Illness and sickness conditions (including pregnancy) and complications of these conditions which existed at the time of completing the Scheme’s application form and which conditions the member was aware of but which were not disclosed in the medical questionnaire which forms part of the application.

  20. Costs in respect of pregnancy, illness or conditions that were specifically subject to waiting periods when the member joined the Scheme.

  21. Health care services relating to any complication that may arise from any exclusion, except for PMBs.

  22. Claims relating to the following:

    22.1 aptitude tests;

    22.2 IQ tests;

    22.3 school readiness tests;

    22.4 questionnaires;

    22.5 treatment in respect of learning problems;

    22.6 treatment in respect of behavioural problems.

  23. The following optical items and/or services are specifically excluded:

    23.1 repairs to frames or lenses;

    23.2 contact lens solution;

    23.3 sunglasses;

    23.4 lens tints equal to or greater than (=>) 35%;

    23.5 tinted contacts lenses.

  24. Claims relating to the following:

    24.1 breathing exercises for chronic obstructive airway diseases;

    24.2 treatment and operations relating to impotence;

    24.3 pre-natal classes;

    24.4 transportation of blood, provided by any institution;

    24.5 expenses incurred in respect of the usage of gold in dentures;

    24.6 treatment relating to Chronic Fatigue Syndrome;

    24.7 prostate ablation in lieu of transurethral resection for non-PMBs;

    24.8 transcatheter aortic valve replacement or implantation for non-PMBs;

    24.9 reversal of sterilisation procedures provided that the Board of Trustees may decide to grant benefits in exceptional circumstances;

    24.10 compensation for pain and suffering, loss of income, funeral expenses or claims for damages;

    24.11 examinations or tests requested for emigration, immigration, insurance policies, employment, admission to school or universities, court medical reports and fitness tests.

  25. Operations, medicines, treatments and procedures for gender alteration or re-alignment for personal reasons and not directly caused by or related to illness, accident or disease.

  26. Reproduction/contraception:

    26.1 all sterilisation procedures e.g. tubal ligation and vasectomy.

    26.2 all forms of contraception including the insertion and/or removal of intra-uterine devices;

  27. Refractive surgery and all types of procedures to improve or stabilise vision, apart from cataracts, except where:

    27.1 hyperopia is measured greater than +3; or

    27.2 myopia is measured more negative than -5; or

    27.3 astigmatism is measured more negative than -2.5.

  28. The excision and/or cautery and/or cryotherapy and/or any other form of treatment of all skin and subcutaneous lesions, both in and out of hospital and irrespective of the type of anesthesia required, including but not restricted to naevi, warts, keratosis, skin tags, sebaceous and other cysts, papillomas, birthmarks, hemangiomata, lipomas, etc. Where it is shown on histology that any skin and subcutaneous lesion that has been removed is malignant, the costs of the procedure that lead to such a diagnosis of that specific lesion will be reimbursed in accordance with the Scheme Rules.

  29. Medication for the treatment of chronic illnesses and conditions, other than the Prescribed Minimum Benefits (PMBs), including but not limited to all costs associated with any admission to hospital for the express or dominant purpose of administering such medication to treat such chronic illnesses and conditions.

  30. Save to the extent specifically provided for in a therapeutic algorithm published by the Minister of Health in the Government Gazette for the treatment of chronic diseases listed as Prescribed Minimum Benefits (PMBs), medication and injection material referred to as biological or specialised drugs or medication.

  31. Unless expressly stated to the contrary or elsewhere in these rules, diagnostic tests and examinations for monitoring purposes, or that do not result in the diagnosis or confirmation of an illness or disease that necessitates surgery.
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