ANNEXURE C

Exclusions

1. With due regard to the Prescribed Minimum Benefits and unless otherwise provided for or decided by the Board, expenses incurred in connection with any of the following will not be paid by the Scheme:

1.1 All Costs of whatsoever nature incurred for treatment of sickness conditions or injuries sustained by a Member or a Dependant and for which any other party is liable. The Member is entitled to such benefits as would have applied under normal conditions, provided that, on receipt of payment in respect of medical expenses, the Member will reimburse the scheme any money paid out by the Scheme in respect of this benefit;

1.2 All Costs which, in the opinion of the Scheme’s medical advisor, are not medically necessary or appropriate to meet the health care needs of the Patient, consistent with the diagnosis or condition; rendered in a cost-effective manner and type of setting appropriate to the supply of the service required for purposes other than comfort or convenience; and consistent in type, frequency and duration of treatment with scientifically based guidelines of medical practice and of demonstrated medical value, unless authorised by the Scheme;

1.3 All Costs in respect of injuries arising from professional sport, speed contests and speed trials;

1.4 All Costs for operations, medicines, treatment and procedures for cosmetic purposes, and any medicines, treatment and procedures resulting from such surgery;

1.5 Holidays for recuperative purposes;

1.6 Purchase:

• Applicators, toiletries and beauty preparations;
• Bandages, cotton wool and other consumable items;
• Patented foods, including baby foods;
• Tonics and slimming preparations;
• Self-medication or drugs and preparations as advertised to the public;
• Household and biochemical remedies; and
• All contraceptives;
• Sunglasses, and optical lens tinting;
• Solution kits for contact lenses;

1.7 All Costs that are more than the annual maximum benefit to which a Member is entitled in terms of the rules of the Scheme;

1.8 Charges for appointments which a Member or dependant of a Member fails to keep;

1.9 Costs for services rendered by -

1.9.1 persons not registered with a recognised professional body constituted in terms of an Act of Parliament; or
1.9.2 any institution, nursing home or similar institution, except a State or Provincial Hospital, not registered in terms of any law;

1.10 Excessive use of drugs or alcoholic liquor, with the exception of Prescribed Minimum Benefits;

1.11 Medical examinations with the intention of taking out insurance cover;

1.12 Interest charges on overdue accounts or legal fees incurred as a result of delayed or non-payment of accounts;

1.13 Treatment and medication of an experimental nature except when administered in an Academic Hospital;

1.14 Drugs which are not registered with the Medicines Control Council and drugs administered for a condition for which it is not registered (“off-label”);

1.15 Fees of services by the Member in respect of himself or any of his Dependants;

1.16 Except for Prescribed Minimum Benefits, no benefits are payable for treatment of obesity, or for diagnostic procedures and treatment related to infertility subject to prevailing hospital-based practice. For the purpose of this rule the word “infertility” shall mean inability to conceive without medical intervention;

1.17 Any costs where a Beneficiary is admitted to hospital for the sole purpose of undergoing investigations which are normally done on an outpatient basis; and

1.18 Any elective or anticipated service or treatment given to a Member or his Dependants outside the borders of the SADC region.

2. Limitation of Benefits

2.1 The maximum benefits to which a member and his dependants are entitled in any financial year are limited as set out in Annexure B;

2.2 Members admitted during the course of a financial year are entitled to the benefits set out in Annexure B, with the maximum benefits being adjusted in proportion to the period of membership calculated from the date of admission to the end of the particular financial year;

2.3 Unless otherwise decided by the Board, benefits in respect of medicines obtained on a prescription are limited to one month’s supply for every such prescription or repeat thereof;

2.4 No benefits will be available for:

2.5 Members requiring chronic medication are required to register their chronic condition with the Managed Care Provider appointed by the Board of Trustees from time to time in order to access authorisation for medication on the condition medicines list. Formulary drugs will be authorised and reference pricing will apply where formulary drugs are unavailable;

2.6 The treatment of chronic conditions, in terms of consultations and procedures, on the Chronic Disease List in terms of the Act are subject to the treatment protocols as implemented by the Managed Care Provider appointed by the Board of Trustees from time to time; and

2.7 Authorisations for any procedure will remain valid only for three (3) months after authorisation date.