1. NAME
The name of the Scheme shall be “PROFMED” Medical Scheme, hereinafter referred to as the “Scheme”.
The Scheme shall be a body corporate and in its own name shall be capable of suing and being sued and of doing or causing to be done all such things as may be necessary for or incidental to the exercise of its powers or the performance of its functions in terms of these rules.
The Registered Office of the Scheme is situated at 6 Anerley Road, Parktown, Johannesburg but the Board may change its Registered Offi ce to any other location in the Republic of South Africa, should circumstances so dictate.
4. DEFINITIONS
In these rules, a word or expression defined in the Medical Schemes Act (Act 131 of 1998) bears the meaning thus assigned to it and, unless inconsistent with the context -
a. a word or expression in the masculine gender includes the
feminine;
b. a word in the singular number includes the plural, and vice
versa; and
c. the following expressions have the following meanings:
4.1 “Act”: the Medical Schemes Act, 1998 (Act No. 131 of 1998), as amended, and the regulations framed thereunder;
4.2 “Administrator”: the Administrator of the Scheme accredited from time to time in terms of the Act;
4.3 “Admission Date”: the date on which a person becomes a Member in terms of these rules;
4.4 “Affiliate”: for the purposes of these rules, means any subsidiary of PPS Limited or any fund, scheme or entity controlled, managed, affiliated to or associated with PPS Limited or any of its subsidiaries;
4.5 “Auditor”: an Auditor registered in terms of the Public Accountants’ and Auditors’ Act, 1991 (Act No. 80 of 1991);
4.6 “Beneficiary”: a Member or a person admitted as a Dependant of a member;
4.7 “Board”: the Board of Trustees constituted to manage the Scheme in terms of these rules;
4.8 “Child”: a Member’s natural Child or a step Child or legally adopted Child or a Child who has been placed in the custody of the Member or his Spouse or Partner and is a Dependant;
4.9 “Condition specific waiting period”: a period during which a Beneficiary is not entitled to claim benefits in respect of a condition for which medical advice, diagnosis, care or treatment was recommended or received within the twelve-month period ending on the date on which an application for membership was made;
4.10 “Continuation Member”: a Member who retains his membership of the Scheme in terms of rule 6.2 or a Dependant who becomes a Member of the Scheme in terms of rule 6.3;
4.11 “Contribution”: in relation to a Member, the amount, exclusive of interest, payable by or in respect of the Member as membership fees;
4.12 “Cost”: in relation to a benefit, the net amount payable in respect of the service rendered or material obtained or pharmaceutical supplied in terms of the Medicines and Related Substances Act, 1965 (Act No. 101 of 1965);
4.13 “Creditable coverage”: any period in which a Late Joiner was:
4.13.1 A Member or a
Dependant of a Medical Scheme;
4.13.2 A Member or a Dependant of an entity doing
the business of a Medical Scheme which, at the time of his or her
membership of such entity, was exempt from the provisions of the
Act.
4.13.3 A uniformed employee of the South African
National Defence Force, or a dependant of such employee, who
received medical benefits from the South African National Defence
Force; or
4.13.4 A Member or a Dependant of the Permanent
Force Continuation Fund, but excluding any period of coverage as a
dependant under the age of 21 years.
4.14 “Date of Service”:
4.14.1 In the event of a
consultation, visit or treatment, the date on which each
consultation, visit or treatment took place, whether for the same
illness or not;
4.14.2 In the event of an operation, procedure or
confinement, the date on which such operation or procedure was
performed or confinement occurred;
4.14.3 In the event of hospitalisation, the date of
each discharge from a Hospital, (or date of cessation of membership,
whichever date occurs first); or
4.14.4 In the event of any other service or
requirement, the date on which such service was rendered or
requirement obtained or received;
4.15 “Dependant”:
4.15.1 A Member’s Spouse
or a former Spouse or a Partner or former Partner of a Member who is
not a Member or a registered Dependant of a Member of another
Medical Scheme;
4.15.2 A Member’s Child, who is not a Member or a
registered Dependant of a Member of another Medical Scheme; who is
not in receipt of a regular remuneration of more than the maximum
Social Pension per month or such greater amount as the rules may
from time to time determine; or a Child who, due to a mental or
physical disability, is Dependent upon the Member and in respect of
whom the Member is liable for family care and support;
4.15.3 A Member’s Child who has reached the age of
legal majority but not more than twenty-five (25) years of age
(including a student at a registered academic institution) who
complies in all respects except age with the definition of “Child”
in rule 4.8 who is Dependent on a Member and who is registered as a
Dependant of that Member in terms of these rules for periods of not
more than twelve (12) months at a time;
4.15.4 The immediate family of a Member in respect
of whom the Member is liable for family care and support and who
should at least be a blood relative in the first degree of the
Member;
4.15.5 Such other persons who are recognised by the
Board as Dependants for purposes of these Rules;
4.16 “Dependent”: in relation to a person other than the Member’s spouse or partner, a Dependant who is not in receipt of a regular remuneration of more than the maximum Social Pension per month.
4.17 “Designated Service Provider”: means a health care provider or group of providers selected by the Scheme as the preferred provider to provide to Members diagnosis, treatment and care in respect of one or more Prescribed Minimum Benefit conditions or any other condition as agreed by the Board from time to time;
4.18 “Domicilium citandi et executandi”: the Member’s chosen physical address at which notices as well as legal process, or any action arising therefrom, may be validly delivered and served;
4.19 “Emergency Medical Condition”: means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical intervention, where failure to provide medical or surgical treatment would result in serious impairment to health, or would place the person’s life in serious jeopardy;
4.20 “General waiting period”: a period in which a Beneficiary is not entitled to claim any benefits;
4.21 “Hospital”: means a State Hospital, a Provincial Hospital, a Private Hospital/Clinic, a nursing home, maternity home, a day clinic, a hospice, a convalescent home or any similar registered institution established in terms of the law;
4.22 “Income”: for the purpose of calculating Contributions in respect of:
4.22.1 Member who is an
employee in terms of rule 6.1.2 - his gross monthly salary/
pensionable Income from all sources;
4.22.2 an individual Member – gross monthly Income
from all sources;
4.22.3 a Member who registers his Spouse or Partner
as a Dependant – gross monthly Income from all sources;
4.22.4 a Continuation Member - gross monthly Income
from all sources;
4.23 “Late Joiner”: an applicant or the adult Dependant of an applicant who, at the date of application for membership or admission as a Dependant, as the case may be, is thirty-five (35) years of age or older but excludes any Beneficiary who enjoyed coverage with one or more Medical Schemes as from a date preceding 1 April 2001, without a break in coverage exceeding three (3) consecutive months since 1 April 2001;
4.24 “Managed Health Care”: clinical and financial risk assessment and management of health care, with a view to facilitating appropriateness and cost-effectiveness of relevant health services within the constraints of what is affordable, through the use of rules-based and clinical management-based programmes;
4.25 “Managed Heath Care Organisation”: a person who has contracted with a medical scheme in terms of regulation 15A to provide a managed health care service;
4.26 “Medical Scheme”: any Medical Scheme registered under Section 24(1) of the Act;
4.27 “Member”: any person who is admitted as a Member of the Scheme in terms of these rules;
4.28 “Member Family”: the Member and all his registered Dependants;
4.29 “NRPL-HS”: National Reference Price List for Health Services as published by the Council for Medical Schemes or any other organisation or body;
4.30 “Patient”: Member or his Dependant receiving medical treatment in terms of the rules of the Scheme;
4.31 “Partner”: a person with whom the Member has a committed and serious relationship akin to a marriage based on objective criteria of mutual dependency and a shared and common household, irrespective of the gender of either party;
4.32 “Pre-authorisation”: shall have the meaning assigned to it in clause 17.1;
4.33 "PPS Limited": Professional Provident Society Limited (Limited by Guarantee), Reg. No. 2001/011016/09;
4.34 “Pre-existing Sickness Condition”: a condition for which medical advice, diagnosis, care or treatment was recommended or received within the twelve (12) month period ending on the date on which an application for membership was made;
4.35 “Prescribed Minimum Benefits”: the benefits contemplated in section 29(1)(o) of the Act, and consisting of the provision of the diagnosis, treatment and care Costs of –
a. the Diagnosis and Treatment Pairs listed in Annexure A of
the Regulations to the Act, subject to any limitations specified
in Annexure A; and
b. any Emergency Medical Condition;
4.36 “Prescribed Minimum Benefit condition”: a condition contemplated in the Diagnosis and Treatment Pairs listed in Annexure A of the Regulations to the Act or any Emergency Medical Condition;
4.37 “Prescription”: all the medicine that a medical or dental practitioner or other person legally authorised to do so prescribes at one time for one person for his sickness, condition or treatment (and meets requirements determined in terms of the Medicines and Related Substances Act (Act No. 101 of 1965);
4.38 “Principal Officer”: the Principal Officer of the Scheme, or a person acting in that capacity by direction of the Board;
4.39 “Profmed Negotiated Tariff”: negotiated with hospitals, hospital groups and service providers from time to time;
4.40 “Profmed Specific Tariff”: determined by the Board of Trustees from time to time using the National Health Reference Price List as published by an appropriate body from time to time and as provided for in Annexure B;
4.41 “Profmed Premium Tariff”: the maximum tariff paid by the scheme as determined by the Board of Trustees from time to time and as provided for in Annexure B;
4.42 “Registrar”: the Registrar or Deputy Registrar of Medical Schemes appointed in terms of section 18 of the Act;
4.43 “SADC”: Southern African Development Community;
4.44 “Scale of Benefits”: the NRPL in respect of health care services determined and published by the Council for Medical Schemes from time to time;
4.45 “Social Pension”: the appropriate maximum monthly basic Social Pension prescribed by regulations promulgated in terms of the Social Assistance Act (Act No. 59 of 1992);
4.46 “Spouse”: the Spouse of a Member to whom the Member is married in terms of any law or custom; and
4.47 “Waiting Period”: a period during which the relevant benefits shall not accrue or be available to a Member or Dependants, but during which period Contributions shall nevertheless be paid to the Scheme.
5. OBJECTS
The objects of the Scheme are -
5.1 to undertake liability in terms of rule 16, in respect of its Members and their Dependants, in return for a Contribution;
5.2 to make provision for the obtaining of any relevant health service;
5.3 to grant assistance in defraying expenditure incurred in connection with the rendering of relevant health service; and/or
5.4 to render a relevant health service, either by the Scheme itself, or by any supplier or group of suppliers of a relevant health service or by any person in association with, or in terms of, an agreement with the Scheme.
