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Private Comprehensive Benefits Overview 2015

7 REASONS why our PRIVATE COMPREHENSIVE option is an excellent choice for your extended and unique healthcare needs:


  • Towers Watson, a leading international professional services company that specialises in risk and financial management, found that our Private Comprehensive option offers 43% more value for money than 48 other equivalent options in the “Comprehensive medical aid” market segment (2015 results).
  • You have the freedom to choose your own private hospital, specialist, doctor or pharmacy (no networks).
  • 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.
  • You don’t have to pay any deposits or co-payments prior to hospitalisation.
  • You have access to R25 000 basic dentistry benefits (refer below table).
  • The average contribution increase of this benefit option was only 1.5% (R30 per adult dependant) for 2015.
  • You will pay low child contributions.

Your cover is made up of three elements:

  1. Your out-of-hospital benefits
  2. Your Basic Dentistry benefits
  3. Your in-hospital benefits

1. OUT-OF-HOSPITAL BENEFITS

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

Subject to your available savings balance, as well as your 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:

  • Specialist   consultations
  • General Practitioner   consultations
  • Prescribed & over   the counter medication
  • Psychologists
  • Optometrists, spectacles & contact lenses
  • Physiotherapy
  • X-rays
  • Pathology (e.g. blood   tests)
  • External appliances   (e.g. hearing aids)
  • Biokinetcis
  • Chiropractic services
  • Dietetic services
  • Speech therapy
  • Audiology
  • 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 smeer, mammogram)
  • Maternity benefits   (e.g. antenatal visits, pregnancy scans)
  • Advanced dentistry   (e.g. orthodontic work, dentures)
  • Homeopaths
  • Some alternative   treatments
  • 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 actual cost up to Medical Aid Rate and is limited to R6 000 per beneficiary per annum.
  • This benefit excludes scans relating to back / neck conditions

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 below benefits / services, 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 the below treatment benefits from your available savings balance, or your own pocket.  Note that sub-limits are applicable on certain benefits.

  • Three (3) general   consultation
  • Unlimited fillings
  • Unlimited tooth   extractions
  • X-rays for conservative   dentistry (excluding wide angle / panorex imaging and MRI / CT scans)
  • Root canal treatment   (excluding wisdom teeth)
  • Two (2) crowns /   temporary crowns (benefit up to R2 500 per crown)
  • 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 < 8 years (benefit up to R9 000; once-only, lifetime benefit)

3. IN-HOSPITAL BENEFITS

We pay for your extensive & comprehensive in-hospital treatment & 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(s)   treatment
  • Unlimited General   Practitioner(s) 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 < 8 years   (benefit up to R9 000;   once-only, lifetime benefit)
  • Major medical illness   cover for cancer, stroke, motor neuron disease & organ transplant (stated   benefits)
  • Maternity confinements
  • 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)

Note:

  • Doctors & 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.

IMPORTANT ASPECTS TO HELP YOU UNDERSTAND YOUR MEDICAL COVER

  • Benefits reflected in this schedule are for the full benefit year and will be pro-rated for 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.
  • Child beneficiaries 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 offers a choice of funding model for members to decide which suits them best. For all approved conditions (including Prescribed Minimum Benefits (“PMBs”)) where treatment is obtained in a private hospital, the benefits and limits as set out in the Rules will apply. Your hospital account will usually be paid in full in terms of tariff agreements with the hospital. The charges of attending doctors / specialists and other healthcare service providers will be reimbursed 200% of scale of benefits (Medical Aid Rate). This funding option applies to all claims for treatment in private hospitals, even if the condition is listed as a PMB. 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 must be obtained in a public hospital 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 are available on the website, or on request from the Scheme.
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