You are on page 1of 14

Your Guide

to Discovery Health Medical Schemes

Classic Saver Plan 2011

You have selected a Classic Saver Plan


There are five plans in the Saver Series Classic Saver, Classic Delta Saver network option, Essential Saver, Essential Delta Saver network option and Coastal Saver
Please keep this information in a safe place for future reference.

Message from Discovery Health


Thank you for giving us the opportunity to look after your healthcare cover needs. You can have peace of mind that Discovery Health places our members first with comprehensive and stable benefits, highly competitive premiums and additional benefits and services to improve the quality of care available to our members. Our strong financial performance, very high levels of reserves and being at the statutory 25% solvency level should give you complete confidence that your medical scheme will be able to pay your claims over the long term. In 2010, the South African healthcare industry underwent many significant changes and developments. Among these are a new proposal on the National Health Insurance and other regulatory changes. Within this changing environment Discovery Health, as the clear market leader, is well equipped to continue to deliver stability of contributions, increased benefits and extra products and services that provide you with significant value. This value is clear in all our members having access to the broadest and deepest level of healthcare cover available in the market. In addition to excellent benefits, Discovery Health continues to invest heavily in our people and technology to ensure that we deliver world-class service to our members, through our call centres and walk-in centres around the country. In an effort to further increase value and improve the quality of care and service convenience for our members, Discovery Health will be reaching into the healthcare system in 2011 to introduce a series of new services. The Discovery Integrated Care Unit offers a specialised treatment approach to members with complex healthcare needs. You will also have access to Discovery Trauma Support Services, available 24/7 for qualified counselling and support after any traumatic event. Our new Discovery Med-Xpress service, rolling out over next year, will allow you to order all medicines telephonically and have them delivered to your home or workplace. This service will also make it easier for you to avoid co-payments on medicine, and will extend your health plans available benefits, with dispensing fees that are at or below the Schemes rate. With DiscoveryCares personal approach to managing chronic and other medical conditions you can also rely on compassionate care and our continued support, when you need us most. Discovery Health provides you with all the tools you need to know your health plan and how to make the most of your cover. We are here to help and guide you in making the best choices when it comes to your healthcare. We look forward to giving you certainty of cover, added value and access to unique benefits and services in 2011. Regards

Dr Jonathan Broomberg CEO: Discovery Health

Milton Streak Principal Officer: Discovery Health Medical Scheme

Contents
Summary of benefits ..................................................................................................................................................1 Discovery Health Plan StarRater ................................................................................................................................2 Cover for medical emergencies .................................................................................................................................4 Hospital benefits ........................................................................................................................................................5 Cover for chronic conditions and oncology ..............................................................................................................8 Out-of-hospital cover .................................................................................................................................................9 General exclusions ....................................................................................................................................................10 Important tips when claiming .................................................................................................................................11

Summary of benefits
The Hospital Benefit covers you if you are admitted to hospital and Discovery Health has confirmed your admission and treatment. You have flexible cover for a list of chronic conditions and cover for cancer, HIV and AIDS. Your health benefits also include cover for medical expenses while travelling in other countries and cover for evacuation for medical emergencies when travelling or working in Africa through the Africa Evacuation Benefit. We pay your day-to-day expenses from the available money in your Medical Savings Account. We extend your day-to-day cover by paying for GP consultations through the Insured Network Benefit. Your plan includes a basic level of cover for a list of medical conditions and treatments defined by the Prescribed Minimum Benefits. These benefits include cover for a list of 271 conditions, most emergency conditions and 27 chronic conditions that includes HIV and AIDS. Medical schemes must provide cover for the diagnosis, treatment and ongoing care of these conditions as long as the tests, investigations and results match all the rules and requirements for cover as a Prescribed Minimum Benefit. These rules and requirements do not apply in life-threatening emergencies. However, once stable you must get treatment from a healthcare provider in the Discovery Health network as soon as possible otherwise you may have to pay a part of the treatment costs yourself. Read more about Prescribed Minimum Benefits on www.discovery.co.za

All our legal rules are available on request


This brochure is only a summary of the benefits and features of the Discovery Health Medical Scheme Plans, pending formal approval from the Council for Medical Schemes. The rules of the Discovery Health Medical Scheme apply to your benefits. If you want to refer to the full set of legal rules on which this brochure is based, please email compliance@discovery.co.za

Detailed information is available on www.discovery.co.za


You can get detailed information on the benefits offered by your plan on www.discovery.co.za

If you want to change your plan


You can change to any other plan at the end of each year with effect from 1 January the following year, not during the year. Please speak

to your financial adviser before you decide to change your plan.

Discovery Health (Pty) Ltd Registration number 1997/013480/07 administers the Discovery Health Medical Scheme Registration number 1125. Discovery Health (Pty) Ltd is an authorised financial services provider.

Discovery Health Plan StarRater


The Discovery Health Plan StarRater is designed to assist you in choosing the right plan for your needs. The StarRater allows you to compare the main benefit categories of in-hospital, day-to-day, chronic and oncology cover provided on each of the Discovery Health Plans. By using the StarRater, you can see, at a glance, how your Discovery Health Plan rates against other plans and make an informed decision about your healthcare cover for 2011.
Series Executive Executive Plan Classic Comprehensive Essential Comprehensive Comprehensive Classic Delta Comprehensive network option Essential Delta Comprehensive network option Classic Priority Priority Essential Priority Classic Saver Essential Saver Saver Coastal Saver Classic Delta Saver network option Essential Delta Saver network option Classic Core Essential Core Core Coastal Core Classic Delta Core network option Essential Delta Core network option KeyCare Plus KeyCare KeyCare Core Plan In-hospital cover Out-of-hospital cover Chronic and oncology cover

See next page for a key to the StarRater

Discovery Health Plan StarRater key


The blue star indicates that you have cover in any hospital. The number of stars refers to the level of cover you have in hospital. In-hospital cover A circled star indicates that to get five-star cover in hospital, you need to use a provider in one of Discoverys networks or payment arrangements either a network hospital or a doctor participating in our direct payments arrangements, or both. All plans except KeyCare To show the level of cover each plan offers for out-of-hospital and day-to-day benefits, weve added together the star-ratings for each of the following: A Medical Savings Account equal to 15% of your total medical scheme contribution. A Medical Savings Account equal to 25% of your total medical scheme contribution. Out-of-hospital cover An additional star if the plan offers the Insured Network Benefit to extend your day-to-day cover. An additional star if the plan offers a limited Above Threshold Benefit. Two additional stars if the plan offers an unlimited Above Threshold Benefit. KeyCare Plus Your plan offers cover in a network for certain day-to-day healthcare costs. You have cover for the conditions listed in the Prescribed Minimum Benefits, but you must use our designated service provider to get your approved chronic medicines, or you will have a co-payment. You have full cover for medicines on our list if you choose a different medicine, you have cover up to a monthly rand amount, except on KeyCare. You must use our designated service provider for cancer treatment. You have cover for the conditions listed in the Prescribed Minimum Benefits you can get your approved chronic medicine from any provider. You have full cover for medicines on our list if you choose a different medicine, you have cover up to a monthly rand amount. If one of the three stars is circled, you must get your approved medicine from our designated service provider or you will have a co-payment. You have cover for the conditions listed in the Prescribed Minimum Benefits, as well as for conditions on an additional disease list. You have full cover for medicines on our list if you choose a different medicine, you have cover up to a higher monthly rand amount than on other plans. You also have higher cover for cancer treatment.

Chronic Illness Benefit and oncology

We want you to be sure the benefits you have available on your health plan meet your individual needs. We understand that its not possible to know exactly what your healthcare needs will be in the next year. You can, however, make sure you understand the benefits you have on the plan you choose and how this will cover you if you need the benefit. Detailed explanations of our benefits are available on www.discovery.co.za

make sure you understand the


benefits you have on the plan you choose

Cover for medical emergencies


Cover for medical emergencies in South Africa
In a medical emergency, call Discovery 911 on 0860 999 911 this number is on your membership card and car sticker for easy reference. If you need medically-equipped transport, for example an ambulance or helicopter, we will cover these costs from your Hospital Benefit, whether you are admitted to hospital or not. In an emergency, go straight to hospital but get someone to call us within 12 hours of your admission. Your emergency treatment in hospital will be covered according to your health plans benefits. There are times when you may not have access to cover on your health plan, for example when you have run out of benefits, reached a benefit limit or you are in a waiting period. Even in these instances, you will still be covered for a life-threatening emergency, which is a Prescribed Minimum Benefit. This means that you have full cover in any hospital until your condition is stable. When your condition is stable and any further treatment you need qualifies as a Prescribed Minimum Benefit, you have the choice to transfer to one of the Schemes designated service providers (a provider or hospital the Scheme chooses) to have full cover. If you choose to get treated in a hospital that is not a designated service provider, we will pay all further claims at up to 80% of the Discovery Health Rate. You will have to pay the balance of all these claims. This co-payment on Prescribed Minimum Benefit treatment in a hospital that is not a designated service provider, will apply to all accounts. This includes the hospital account and related accounts. A related account is any account other than the hospital account, for example accounts from the admitting doctor, anaesthetists and accounts for other approved healthcare expenses you incur, like all radiology and pathology accounts.

Cover for HIV prophylactics


If you need HIV prophylactics to prevent HIV infection from mother-to-child transmission, occupational and traumatic exposure to HIV or sexual assault, call us immediately on 0860 99 88 77, as treatment must start as soon as possible.

What is a medical emergency?


A medical emergency is the sudden and, at the time, unexpected onset of a health condition that needs immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the persons life in serious jeopardy.

Cover for going to casualty


If you are admitted to hospital from casualty, we will cover the costs of the casualty visit from your Hospital Benefit, as long as we confirm your admission. If you go to a casualty or emergency room and you are not admitted to hospital, we will pay the costs from your day-to-day benefits. Some casualties charge a facility fee, which we do not cover.

Cover for evacuation in Africa


The Africa Evacuation Benefit covers you for emergency medical evacuations from certain sub-Saharan African countries back to South Africa. You can find the list of African countries this benefit covers and the details of the cover before travelling on www.discovery.co.za All emergency treatments outside the borders of South Africa must be confirmed by calling International SOS on+ 27 11 541 1222. This number is displayed on your membership card.

Cover while travelling overseas


The International Travel Benefit provides cover of up to R5 million for each person on each journey for emergency medical costs while you travel outside South Africa. This cover is for a period of 90 days from your departure from South Africa. Cover includes appropriate emergency evacuation and transport if needed. You pay the first 100 or US $150 of day-to-day medical expenses. Please find out how the International Travel Benefit works before you travel overseas and also read the scheme exclusions. Contact us to get detailed information or go to www.discovery.co.za All emergency treatments outside the borders of South Africa must be confirmed by calling International SOS on + 27 11 541 1222. This number is displayed on your membership card.

Benefit tips...
Call 0860 999 911 in an emergency Let us know about your admission within 12 hours of being admitted Make sure you know how the International Travel Benefit works before going overseas

Hospital benefits
Important information about your hospital cover
Your hospital cover is made up of:
the cover for the account from the hospital, and the cover for all other accounts, like accounts from your admitting doctor, anaesthetist or

other healthcare expenses. We call these related accounts. Limits, clinical guidelines and policies apply to some healthcare services and procedures.

1. How we pay the account from the hospital


We cover you in a private hospital for emergency and planned hospital admissions that you have confirmed with us. There is no overall limit to your hospital cover on the Classic Saver Plan. We cover your hospital account (the ward and theatre fees) at the rate agreed with the hospital. You have cover for a general ward, not a private ward.

We cover you in hospital for emergency and planned hospital admissions. In an emergency, go straight to hospital but call us or get someone to call us within 12 hours. For planned hospital admissions, please call us at least 48 hours before you go to hospital to confirm your admission.

2. Accounts from your doctor and other healthcare services


Your doctor or treating healthcare professionals accounts are separate from the hospital account and are called related accounts. Related accounts include any accounts other than the hospital account. Examples of related accounts are the accounts from the admitting doctor, anaesthetist and any approved healthcare expenses, like radiology or pathology, which you incur during your hospital stay. Refer to page 6 for detailed information on how we cover related accounts. Please contact us before you receive treatment for which we have not confirmed your benefits or to extend your hospital stay.

What to do before you go to hospital


Before you go to hospital for any planned procedure, you must:
see your doctor who will decide if it is necessary for you to be admitted choose your admitting doctor choose which hospital you want to be admitted to find out how we cover other healthcare professionals, for example your anaesthetist

Remember that you can reduce the risk of a co-payment by using a doctor who participates in one of our direct payment arrangements. We cover your approved hospital procedures and consultations with these doctors in full. Healthcare professionals who participate in our payment arrangements are also the designated services providers for Prescribed Minimum Benefits. If you use another specialist, we will cover your accounts up to a maximum of 200% of the Discovery Health Rate on the Classic Saver Plan.

see Remember on the right-hand side of this page.


call us on 0860 99 88 77 to confirm your hospital admission at least 48 hours before you go

Benefit tips...
You can access the MaPS tool on www.discovery.co.za to search for healthcare professionals who are on our payment arrangements

in. We will give you information that is relevant to how we will pay your hospital stay. If you do not confirm your admission, we will only pay 70% of the costs that we would normally cover. Please refer to page 4 for more information on emergencies.

Cover is subject to our rules


We pay medically appropriate claims. Your cover is subject to our scheme rules, funding guidelines and clinical rules.There are some expenses that you may incur while you are in hospital that your Hospital Benefit does not cover, for example private ward costs. Certain procedures, medicines or new technologies need separate approval while you are in hospital. You can find out more about our clinical rules and policies for cover by contacting us at www.discovery.co.za/portal/individual/benefits-dwc

You can benefit by using healthcare professionals participating in our payment arrangements because we will cover their approved procedures in full.

How we cover your healthcare professionals


Full cover for specialists participating in our payment arrangements
You can benefit by using healthcare professionals participating in our payment arrangements because we will cover their approved procedures in full. If you are a Classic Saver Plan member, you benefit from access to the broadest range of specialists who we pay in full, which represents over 87% of specialist interactions. Healthcare professionals who participate in our payment arrangements, appropriate to your plan, are also the designated service providers for Prescribed Minimum Benefits. You can access the MaPS tool on www.discovery.co.za to search for healthcare professionals who participate in our payment arrangements.

Cover for Prescribed Minimum Benefits


According to the Prescribed Minimum Benefits, in certain circumstances you have the right to get a basic level of cover for a list of medical conditions and treatments. These benefits include cover for a list of 271 listed conditions, most emergency conditions and 27 listed chronic conditions that include HIV and AIDS. Medical schemes must provide cover for the diagnosis, treatment and costs of the ongoing care of these conditions.

To access Prescribed Minimum Benefits, there are certain rules that apply:
Your medical condition must be part of the list of defined

conditions for Prescribed Minimum Benefits


The results of your medical tests and investigations must match the

You may have a co-payment if you use other specialists


If you are treated in hospital by a specialist who does not participate in one of our payment arrangements, we cover your accounts up to 200% of the Discovery Health Rate on the Classic Saver Plan.

requirements for diagnosis of your medical condition


The treatment you need must match the treatments listed in the

Prescribed Minimum Benefits as appropriate for your medical condition


You must use a doctor, specialist or other healthcare professional in

the Discovery Health network. This does not apply in life-threatening emergencies. However, even in these cases, once your condition stabilises you must access a healthcare professional in the Discovery network as soon as possible otherwise you may be responsible to pay part of the treatment costs yourself. Contact us for more information on our approach to Prescribed Minimum Benefits or go to www.discovery.co.za

Other healthcare professionals


We cover GPs and other healthcare services up to 200% of the Discovery Health Rate on the Classic Saver Plan. We cover radiology and pathology up to 100% of the Discovery Health Rate.

Benefit tips...
You must call us at least 48 hours before any planned procedure You will be covered in full if you use doctors in our payment arrangements relevant to your plan type Go to Do We Cover on www.discovery.co.za to find out more about our clinical rules and policies Some treatments you receive while in hospital may need separate approval or benefit confirmation

Cover for investigations


Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy)
We pay the first R2 375 of your hospital account from your day-to-day benefits. We pay the balance of the hospital account and your related accounts from your Hospital Benefit. We pay related accounts up to 200% of the Discovery Health Rate on the Classic Saver Plan. Contact us for a detailed explanation of how we cover scopes or go to www.discovery.co.za

Severe dental and oral surgery


The Severe Dental and Oral Surgery Benefit covers a defined list of procedures, with no deductible and no overall limits. This benefit is subject to authorisation and the Schemes clinical entry criteria.

Unlimited healthcare services


Most of your in-hospital healthcare services have no overall limit. These include:
GPs Specialists Allied healthcare professionals, for example physiotherapists Pathology and radiology HIV cover if you are registered on the HIVCare Programme.

MRI and CT scans


If your MRI or CT scan is done as part of an approved admission, we pay it from your Hospital Benefit. If you are admitted for conservative back or neck treatment, or the scan is unrelated to your admission, we pay the first R2 100 of the scan code from your day-to-day benefits. We pay the balance from your Hospital Benefit up to 100% of the Discovery Health Rate. Contact us for a detailed explanation of how we cover MRI and CT scans or go to www.discovery.co.za

Only the following healthcare services have an annual limit:


Hospital limits Cochlear implants, auditory brain implants and processors Internal nerve stimulators Hip, knee and shoulder joint prostheses Prosthetic devices used in spinal surgery Mental health benefit Alcohol and drug rehabilitation Terminal care benefit Chronic dialysis Annual limit R133 000 for each person for each benefit R101 000 for each person There is no overall limit if you get your prosthesis from a preferred supplier. If you choose not to, a limit of R33 000 will apply to each prosthesis. R21 000 for the first level, R42 000 for two or more levels, limited to one procedure for each person 21 days for each person 21 days for each person R25 250 for each person We cover these expenses in full if we have approved your treatment plan and you use a provider in our network. If you go elsewhere, you will be responsible for a co-payment

Your cover for dental treatment in hospital


You need to pay a portion (deductible) of your hospital or day clinic account upfront for dental admissions. This amount varies depending on the members age and the place of treatment.
Members Members younger than 13 years Members 13 years and older Hospital R1 200 R3 000 Day clinic R600 R2 000

We pay the balance of the hospital account from the Hospital Benefit up to 100% of the Discovery Health Rate. You can access the MaPS tool on www.discovery.co.za to search for day clinics that you can use. We pay the related accounts, which include the dental surgeon and anaesthetists accounts, from the Hospital Benefit up to 100% of the Discovery Health Rate.

No overall dental limit


There is no overall limit for dental treatment. We will pay the costs of all dental appliances and orthodontic treatment (including the related accounts for orthognathic surgery) from your Medical Savings Account up to 100% of the Discovery Health Rate regardless of place of treatment, as long as you have money available.

Cover for chronic conditions


You have flexible cover for chronic conditions, HIV and AIDS and cancer

Chronic Illness Benefit


You have flexible cover for 27 Chronic Disease List conditions. You have full cover for approved medicine on Discovery Healths medicine list (formulary) or up to a set monthly amount (Chronic Drug Amount) for medicine not on our list. You will be responsible for the balance if your medicine costs more than the Chronic Drug Amount.

Your cover for HIV and AIDS


For members living with HIV and AIDS, the HIVCare Programme provides comprehensive disease management. We take utmost care to protect the right to privacy and confidentiality of our members. To have access to cover for hospitalisation for conditions related to HIV, and to antiretroviral therapy, you must enrol on the HIVCare Programme.

We need to approve your application


We need to approve your application before we cover your condition from the Chronic Illness Benefit. To apply, contact us to get an application form or go to www.discovery.co.za. Complete the relevant application form with your doctor and send it to us. We will send you a letter detailing the cover available to you. We pay medicine up to a maximum of the Discovery Health Medication Rate. Please note that the medicine list (formulary) and the Chronic Drug Amount may change from time to time. Visit www.discovery.co.za or contact us for a detailed explanation of the cover offered through the Chronic Illness Benefit.

Your cover for cancer treatment


The DiscoveryCare Oncology Programme covers the first R200 000 of your approved cancer treatment over a 12-month cycle, in full. Cover is unlimited once your cancer treatment costs go over this amount, but you will need to pay 20% of the costs of all further treatment from your pocket. We cover chemotherapy and any oncology-related medicines up to the Discovery Health Medication Rate. Consultations, radiotherapy, radiology, pathology and scans are paid up to 100% of the Discovery Health Rate. You may be responsible for a co-payment if your healthcare provider charges more than the applicable Discovery Health Rate. Cancer treatment that falls within the Prescribed Minimum Benefits is always covered in full, with no co-payment. Please call us to register on the Oncology Programme. Visit www.discovery.co.za for a detailed explanation of the cover offered through the Oncology Programme.

What we cover as a Prescribed Minimum Benefit


The Chronic Illness Benefit covers certain diagnostic tests, consultations and medicines each year for the chronic conditions listed in the Prescribed Minimum Benefits, called the Chronic Disease List. This cover includes tests and consultations during the year for both the diagnosis and ongoing management for each condition. If you do not use healthcare providers in the Discovery Health networks (designated service providers) to receive the treatment, you will have to pay part of the treatment costs yourself. Contact us for the latest copy of the treatment guidelines or go to www.discovery.co.za

Benefit tips...
ou must register for cover from the Y Chronic Illness Benefit. We offer you comprehensive cover for a list of conditions ead more about the cover for R chronic conditions, HIV and AIDS and cancer on www.discovery.co.za or contact us ou must register on the Y DiscoveryCare programmes to access the benefits ore details are available on M www.discovery.co.za or you can contact us

Cover for day-to-day medical expenses


We first pay your claims from your Medical Savings Account
We pay for your day-to-day medical expenses like GP visits, x-rays and blood tests from your Medical Savings Account, as long as you have money available. Your Medical Savings Account is an amount that you get at the beginning of the year or when you join Discovery Health. You have access to this amount from day one. If you have funds in your Medical Savings Account at the end of the year, we will carry over these funds to the next year. You may need to pay for your day-to-day medical expenses if you have run out of money in your Medical Savings Account. If you leave Discovery Health or downgrade your health plan before the year is up, you will owe Discovery Health the portion of the Medical Savings Account you have used but have not yet paid back.

Your Medical Savings Account is an amount that you get at the beginning of the year or when you join Discovery Health. You have access to this amount from day one.
Further extensions to your day-to-day cover
Discovery Health pays claims for some day-to-day expenses to make the money in your Medical Savings Account last longer.
The Screening and Prevention Benefit covers a range of

Annual Medical Savings Account amounts*:


Main member Adult dependant Child ** R4 548 R3 576 R1 812

healthcare services, including the following tests at a Discovery Wellness Network provider: blood glucose, blood pressure, cholesterol and body mass index. The benefit also covers a mammogram, Pap smear, PSA and HIV screening tests. Members from the age of 65 and members registered for certain chronic conditions are also covered for a seasonal flu vaccine from this benefit
We will cover out-of-hospital claims for your recovery after

* We prorate this benefit according to when you join the medical scheme ** We count a maximum of three children when we calculate the annual Medical Savings Account amounts

certain traumatic events from the Trauma Recovery Extender Benefit. The cover applies for the rest of the year in which the trauma takes place, as well as for the year after your trauma.
We also cover scopes (gastroscopy, colonoscopy, sigmoidoscopy

The Insured Network Benefit ensures you have no gaps in cover for GPs
We further extend your day-to-day cover through the Insured Network Benefit by paying for GP consultation fees when you have spent your annual Medical Savings Account deposit. We cover the cost of your consultations if you go to a GP in our network. The maximum number of consultations that we cover for a single member and a family each year depends on your plan type:
Health plan Classic Saver Plan Single member 3 consultations Family 6 consultations

and proctoscopy) done in your doctors room. Discovery Health pays for these claims without using your Medical Savings Account as we pay these accounts from the Hospital Benefit. We pay up to 200% of the Discovery Health Rate on a Classic Saver Plan. Please call us before you have a scope in your doctors rooms to confirm your benefits. A detailed explanation of how these benefits work is available on www.discovery.co.za or you can contact us.

This GP benefit only covers the consultation fee (code 0190, 0191 or 0192). We pay for any other healthcare services from your available day-to-day benefits. The list of GPs participating in the Discovery Health GP Network is available on www.discovery.co.za/MaPS

Benefit tips...
How to make the money in your Medical Savings Account go further: Choose a GP in the Discovery Health GP Network Choose a specialist who is part of our payment arrangements Use generic medicines and dont pay for over-the-counter medicines (OTCs) from your MSA Ask your healthcare professional to use the Discovery Health pathology form

Treatment in hospital that we cover from your day-to-day benefits


We cover the following treatment you get in hospital from your Medical Savings Account:
Casualty treatment if you are not admitted Medicine to take home External medical items.

There is no annual limit on these healthcare services


We pay for these healthcare services from your Medical Savings Account as long as you have funds available:
GPs Specialists Allied healthcare professionals, for example physiotherapists Radiology and pathology Dentistry Mental health benefit (including psychologists and psychiatrists) Private nursing Prescribed and over-the-counter medicine External medical items Hearing aids Optical care We will pay the first R2 100 of your MRI or CT scan code from

your Medical Savings Account. We cover the balance from your Hospital Benefit up to the Discovery Health Rate.

General exclusions
The Discovery Health Medical Scheme has certain exclusions. Discovery Health will not pay for healthcare services related to the following, except where stipulated as part of a defined benefit or under the Prescribed Minimum Benefits.
General exclusion list 1. Cosmetic procedures and treatments 2. Otoplasty for bat-ears, portwine stains and blepharoplasty (eyelid surgery) 3. Breast reductions or enlargements and gynaecomastia 4. Obesity 5. Frail care 6. Infertility 7. Wilfully self-inflicted illness or injury 8. Alcohol, drug or solvent abuse 9. Wilful and material violation of the law or during a period of imprisonment 10. Wilful participation in war, terrorist activity, riot, civil commotion, rebellion or uprising 11. Injuries sustained or healthcare services arising during travel to or in a country at war 12. Experimental, unproven or unregistered treatments or practices 13. Search and rescue 14. Any costs for which a third party is legally responsible We also do not cover the complications or the direct or indirect expenses that arise from any of the exclusions listed above, except where stipulated as part of a defined benefit or under the Prescribed Minimum Benefits. If we apply waiting periods because you have never belonged to a medical scheme or have had a break in membership of more than 90 days before joining Discovery Health, you will not have access to the Prescribed Minimum Benefits during your waiting periods. This includes cover for emergency admissions.

10

Important tips when claiming


When claiming from Discovery Health for your medical costs, whether these are hospital, chronic or day-to-day, these steps apply.
Check with your healthcare professional if they have sent your claims to us to avoid duplicates Send your claims within four months, otherwise we will consider them expired and not pay them When sending claims, please make sure the following details are clear:

1. Your membership number 2. The service date 3. Your doctors details and practice number 4. The amounts charged 5. The relevant consultation, procedure or NAPPI code and diagnostic (ICD-10) codes 6. The name and birth date of the dependant for whom the service was done 7. If paid, attach your receipt or make sure the claim says paid
Remember to always keep copies of your claims for your records To see the status of your claim, you can go to www.discovery.co.za

You can send us your claims in the following ways


Email
You can scan and email your claims to claims@discovery.co.za

Post
You can post your claims to the following address: Discovery Claims PO Box 784262 Sandton 2146

Claims drop-off boxes


GM_9571DHM_28/02/11 C-FFE 10/10 (11)

You can drop your claims in our claims drop-off boxes situated around the country in convenient places such as pharmacies and medical practices, as well as at most Virgin Active or Planet Fitness gyms.

11