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Comprehensive Medical Cover

Private Comprehensive Benefits Overview 2016

When selecting a medical scheme benefit option, one of the most important considerations is the level of in-hospital insurance cover you are buying. Factors such as unlimited hospitalisation vs capped / limited cover, reimbursement of claims at 100% or 200% of the medical scheme rate, freedom of choice vs the limitation of network hospitals or doctors and the solvency of a particular medical scheme are all significantly important questions to ask.

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. Out-of-hospital benefits are usually funded from the member’s savings account and annual limits may apply.

In a recent benchmarking exercise conducted by Towers Watson, a leading international professional services company, it was found that the Genesis Private Comprehensive benefit option offers 43% more value for money than 48 other equivalent options in the “Comprehensive Medical Cover” segment.


6 REASONS why our PRIVATE COMPREHENSIVE option offers excellent value for money for your extended healthcare needs:

bullet  You have the freedom  to choose your own private hospital, specialist, doctor or pharmacy (no networks).
bullet All hospital and related accounts are usually settled in full at the rate agreed between Genesis and the private hospital group, while specialists and doctors will be covered up to 200% of Medical Aid Rate.
bullet You don’t have to pay any deposits or co-payments prior to hospitalisation.
bullet You have access to R25 000 basic dentistry benefits (refer below table).
bullet The average contribution increase of this benefit option was only 3.6% (R75 per adult dependant) for 2016.
bullet You will pay low child contributions.

Your medical cover consists of three elements:

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

 1. OUT-OF-HOSPITAL BENEFITS

We pay for your extensive day-to-day healthcare needs

Subject to your available savings balance and / or defined benefits in respect of consultations and medication, you will enjoy comprehensive cover for the following benefits when obtained from a provider 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
  • Social workers
  • 24-hour access to an Emergency   Helpline (ER24 / 084 124)
  • Preventative care (e.g. baby immunisations, flu vaccines)
  • Preventative screening tests (e.g. pap smear, mammogram)
  • Homeopaths and some alternative treatments, e.g. hypnosis for smoking cessation

We also cover out-of-hospital MRI / CT scans 

  • MRI / CT scans done out-of-hospital will be covered at 50% of the lower of cost or Medical Aid Rate and is limited to R6 000 per beneficiary per annum.

2. R25 000 BASIC DENTISTRY BENEFITS

We pay for your basic dentistry treatment

These unique annual 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 your risk benefits and, provided that your Dental Practitioner charges you Medical Aid Rates, you should not have to fund these benefits from your available savings balance, or your own pocket.  Note that sub-limits are applicable on certain benefits.

  • Three (3) dental consultations p.a
  • Six (6) fillings p.a
  • Unlimited tooth extractions
  • Six (6) X-rays for conservative dentistry (excluding wide angle / panorex imaging and MRI / CT scans) p.a
  • Two (2) root canal treatments (excluding wisdom teeth) p.a
  • Crowns, dentures or bridges limited to the lower of cost or Medical Aid Rate, further limited to R3 000 p.a
  • Surgical removal of impacted wisdom teeth, where pathology and pain are directly associated with the wisdom teeth (benefit up to R9 000 per case)
  • In-hospital extractions & fillings for children < 9 years (benefit up to R9 000; once-only, life-time benefit)

 3. IN-HOSPITAL BENEFITS

We pay for your comprehensive in-hospital treatment

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   impacted wisdom teeth, where pathology and pain are directly associated with   the wisdom teeth (benefit up to R9 000 per case)
  • Extractions & fillings for children < 9 years   (benefit up to R9 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 savings balance)
  • Other elective procedures (subject to available savings balance)

Notes:

  • 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.
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