Monthly Member Statement

Statement Date: 30/11/2019

Medical Scheme Details

Mr T.C. Mutetwa BONITAS MEDICAL FUND

4 Nolloth Road PO BOX 1101

FLORIDA GLEN
Krugersrus
1708
1559

Contact Details
Call Centre Number /Lost Cards: 0860 00 2108
Fraud Hotline Number: 0800 11 2811
Web Address: www.bonitas.co.za
Email Address: queries@bonitas.co.za

Member Details
Member Number: 46900002234 Telephone Number(s): 0122531092 0719466773
Previous Member Nr: Cellular Number: 0712182560
Option: PRIMARY SELECT Email Address: mutetwac@dws.gov.za
Option Start Date: 01/01/2019 Pay Point: 469/032/DWA - DEPARTMENT OF WATER AFFAIRSWATER TRADING ACCOUNT W
Bank Account: ABSA Bank, Branch 632005, Current Account Number ******5183

Member Beneficiary Status

Code Beneficiary Type Beneficiary Name Date of Birth Identity Number Status Scheme Join Date Benefit Date Scheme Left Date
00 Principal Member TAWANDA CHARLES MUTETWA 29/07/1979 7907296012189 Active 01/03/2011 01/03/2011
01 Adult Dependant SEHLISELO MUTETWA 02/08/1980 DN555221 Active 01/03/2011 01/03/2011
02 Child Dependant NOKUTENDA MICHELLE MUTETWA 23/05/2010 NM23052010 Active 01/03/2011 01/03/2011
03 Child Dependant TENDAI CHALTON MUTETWA 06/11/2013 TC06112013 Active 06/11/2013 06/11/2013
04 Child Dependant TATENDA CHARLENE MUTETWA 06/11/2013 TA06112013 Active 06/11/2013 06/11/2013
Member Number: 46900002234 Statement Date: 30/11/2019 Page 2

Limit Utilisation Summary ***

Limit Code Limit Description Limit Type Beneficiary Name Start and End Date Limit Used Available
01 Overall Annual Limit Family 01/01/2019 - 31/12/2019 Unlimited R30891.80
01.05 Day-to-Day Benefits Family 01/01/2019 - 31/12/2019 R5660.00 R5073.41 R586.59
07.04 Consultations & Visits - GPs Family 01/01/2019 - 31/12/2019 R5030.00 R4782.80 R247.20
07.26 Consultations - GP - Non-Network Family 01/01/2019 - 31/12/2019 R1750.00 R1750.00 R0.00

Claims Processed and Paid to the Healthcare Professional (HCP)

Claims Detail Claims Payment Information* Reason Codes****
Beneficiary Treatment Tariff/Nappi Charged Tariff Scheme Total Claim Member Refund to Payment Payment
Date Code** Amount Amount Paid HCP Shortfall Owes Member Date Reference
Scheme Number
Hoppies Pharmacy (Practice number: 6024602)
04 Tatenda 21/11/2019 778567001 89.84 89.84 89.84 0.00 0.00 0.00 28/11/2019 50802265
03 Tendai 21/11/2019 830739009 18.25 18.25 0.00 18.25 0.00 0.00 5014
01 Sehliselo 21/11/2019 782017002 212.08 177.59 177.59 34.49 0.00 0.00 28/11/2019 50802265 387/535
Total: 320.17 285.68 267.43 52.74 0.00 0.00
Dr Johan Nell (Practice number: 1447947)
04 Tatenda 30/09/2019 0190 379.10 379.10 379.10 0.00 0.00 0.00 28/11/2019 50798405
03 Tendai 21/11/2019 830739009 18.25 18.25 18.25 0.00 0.00 0.00 28/11/2019 50798405
03 Tendai 21/11/2019 853003009 34.63 34.63 34.63 0.00 0.00 0.00 28/11/2019 50798405
03 Tendai 21/11/2019 766801004 23.48 18.52 18.52 4.96 0.00 0.00 28/11/2019 50798405 387/535
03 Tendai 21/11/2019 0190 379.10 379.10 379.10 0.00 0.00 0.00 28/11/2019 50798405
04 Tatenda 21/11/2019 0190 379.10 379.10 379.10 0.00 0.00 0.00 28/11/2019 50798405
Total: 1213.66 1208.70 1208.70 4.96 0.00 0.00
Medirite Palm Spring (Practice number: 0345113)
04 Tatenda 21/11/2019 853003009 34.04 33.45 33.45 0.59 0.00 0.00 28/11/2019 50791361 387/535
Total: 34.04 33.45 33.45 0.59 0.00 0.00
Jacobs B J (Practice number: 1607499)
01 Sehliselo 22/10/2019 0190 700.00 381.30 0.00 318.70 0.00 381.30 06/11/2019 58992 535
01 Sehliselo 22/10/2019 5100 403.60 0.00 0.00 403.60 0.00 0.00 23
01 Sehliselo 22/10/2019 0190 700.00 0.00 0.00 700.00 0.00 0.00 23
01 Sehliselo 22/10/2019 5100 403.60 0.00 0.00 403.60 0.00 0.00 23
01 Sehliselo 22/10/2019 5100 403.60 0.00 0.00 403.60 0.00 0.00 23
Member Number: 46900002234 Statement Date: 30/11/2019 Page 3

Claims Processed and Paid to the Healthcare Professional (HCP)

Claims Detail Claims Payment Information* Reason Codes****
Beneficiary Treatment Tariff/Nappi Charged Tariff Scheme Total Claim Member Refund to Payment Payment
Date Code** Amount Amount Paid HCP Shortfall Owes Member Date Reference
Scheme Number
01 Sehliselo 22/10/2019 0190 700.00 0.00 0.00 700.00 0.00 0.00 23
01 Sehliselo 22/10/2019 5100 403.60 0.00 0.00 403.60 0.00 0.00 23
Total: 3714.40 381.30 0.00 3333.10 0.00 381.30
Grand Total: 5282.27 1909.13 1509.58 3391.39 0.00 381.30

Summary of Financial Transactions (Refunds & Monies owed to Scheme)

Date Description Payment Reference Number Transaction Amount Cumulative Balance
Opening Balance 0.00 0.00
31/10/2019 Claims -381.30 -381.30
06/11/2019 Payment/Refund 381.30 0.00
30/11/2019 Closing Balance 0.00
Amount owed by the Member to the Scheme: 0.00

Tariff/Nappi Codes Description **

Tariff Code Tariff Code Description
0190 New and established patient: Consultation/visit of a new or established patient of an average duration and/or complexity. Includes counselling with the patient and/or family and co-ordination with other health
care providers or liaison with third parties on behalf of the patient
5100 Pelvic organs ultrasount: transvaginal or trans rectal probe
766801004 STILPANE
778567001 WAXSOL NF 10ML
782017002 ELOCON
830739009 ZOXIL S
853003009 BETAFED

Reason Codes Description****

Code Reason Code Description
23 This is a duplicate claim line which has been previously processed.
387 Claim amount reduced according to the list of medicines approved by the scheme.
535 Claimed amount has been reduced and paid at your scheme rate.
5014 The medication supplied exceeds the approved quantity.
Member Number: 46900002234 Statement Date: 30/11/2019 Page 4

Important Message
If your doctor or medical facility uses an ICD-10 code on a claim that does not comply with the ICD-10 clinical code rules, it will be rejected. They will need to resubmit the claim with the correct ICD-10 code/s. For more info.
go to http://www.health.gov.za/icddoc.php.
For your convenience, all Chronic Medicine queries or updates can now be done by calling your Scheme Call Centre number mentioned above under contact details. We have an improved chronic medicine updating
process. Ask your dispensing pharmacy to submit a claim first, as your new medicine may be listed in a pre-approved basket linked to your authorised chronic condition. You, your doctor, pharmacist or broker can contact us
for the following reasons: * first time registration
* a new condition or medicine that needs further motivation
* if the claim is not successfully processed (in which case the system will generate a message to the pharmacist).
View the baskets and register or update chronic medicine online 24/7 by logging in on www.bonitas.co.za.
To avoid postal delays, we would encourage you to either e-mail your current claims ( valid claims within 4 months of treatment date) to claims@bonitas.co.za or fax to 011 758 7760
Managed Care Funding Protocol.
Also known as out-of-hospital Care Templates or Baskets of Care.
Certain conditions have Baskets of Care, that will assist you to manage your condition optimally out-of-hospital. These may include doctor consultations, radiology and pathology tests. We are in the process of improving the
way these benefits are displayed on the monthly statements, to make it easier for you to manage your condition and track your available benefits. During this process the Baskets of Care will be temporarily removed from
your statement. This will in no way influence access to your benefits.
Important note: Benefits may overlap in the different Care Baskets. These benefits will be combined to give you access to the higher amount of benefits and will not be added onto the benefits.
EXAMPLE: If you have 3 GP consultations for Asthma and 2 GP consultations for Diabetes, a maximum of 3 GP consultations will be authorised, to be used for both conditions and not 5 GP consultations.
Please note: Product rules, limits, terms and conditions apply. Where there is a discrepancy between the content provided in this statement, the website and the Fund Rules, the Fund Rules will prevail. The
Fund Rules are available on request and also on www.bonitas.co.
Hospital admissions to non-network hospital will attract a 30% co-payment except in the case of a bona fide emergency.
Member Zone:
Have you downloaded your free discounted vouchers yet? Register on our Member Zone at https://bit.ly/2HseKqp and see how to make most of your medical aid.
Bonitas Walk-In Centres
Bloemfontein: Middestad Centre, Shop C7, 1st Floor, C/O Charles & West Burger Street Bloemfontein
Cape Town (Bellville): Sanlam Centre, 2 Strand Road Cape Town
Cape Town: Icon Building, Ground Floor, Cnr Lower Long Street and Hans Strijdom Avenue Cape Town
Durban: 102 Stephen Dlamini Road Durban
East London: MBMed F1 Site 7 Settlers Way East London (MBMed staff only)
Exxaro Pretoria: Exxari Corporate Centre c/o Roger Dayson & Voortrekker Road Pretoria West (Only Exxaro staff)
Johannesburg: Mathomo Mall, 115 Main Street, Marshalltown
Kathu: Shop 18D Kameeldoring Plein Building Cnr Frikkie Meyer and Rooisand Road Kathu, North Cape
Klerksdorp: Medicover Building Shop 11, 22 Knowles Street Witkoppies Klerksdorp
Kimberley: Shop no 17, Southey Street Kimberley
Lephalale: Bosveld Boulevard Park, Shop 6, Cnr of Chris Hani and Joe Slovo street, Onverwacht Lephalale
Mafikeng: Office 101A 1st Floor East Gallery Mega City Mafikeng
Mbombela: Union Square Unit G2, 44 Mostert Street Mbombela
Member Number: 46900002234 Statement Date: 30/11/2019 Page 5

Important Message
Northam: 180 Botha Street Northam
Polokwane: Checkers Centre, Shop 2 Ground Floor, Cnr Hans van Rensburg Street & Grobler Street, Polokwane
Pretoria: Nedbank Plaza, Shop 17, Ground Floor, 361 Steve Biko Street, Arcadia Pretoria
Port Elizabeth: Greenacres Office Park, Block 6, 2nd Avenue, Newton Park Port Elizabeth
Roodepoort: Flora Centre -Entrance 2, Shop 21 & 22, Cnr. Ontdekkers and Conrad Road, Florida North Roodepoort
Rustenburg: Lifestyle Square, Shop No 23, Beyers Naude Drive Rustenburg (Bonitas and Polmed)
Secunda: Grand Palace, Unit 82, 2302 Heunis Street Secunda
Vereeniging: 36 Merriman Avenue, Ground Floor Vereeniging
The document(s) may contain confidential health information that is legally privileged and intended for the member only. Bonitas Medical Fund cannot be held responsible if it is sent to any other person in error or
intentionally. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of the document(s) is strictly prohibited. If you have received this
information in error, please notify the sender immediately and arrange for the return or destruction of these documents.