Going to see a healthcare provider

Out-of-hospital doctor visits

Where possible, make use of general practitioners and specialists on the Scheme's network lists, to optimise benefits and minimise co-payments for treatment.

General practitioners not on the network list will be paid up to 80% of the Medical Scheme Rate. If the healthcare provider charges more, you will have to pay the difference.

Specialists not on the Scheme's network lists will be paid up to the Medical Scheme Rate. If the healthcare provider charges more, you will have to pay the difference.

Visits with general practitioners and specialists out-of-hospital are subject to the overall day-to-day limit. If you have chosen Option B and have selected the Personal Medical Savings Account (PMSA) autopay option, co-payments may be covered from your available PMSA balance.

Hospital admission and treatment whilst in hospital

The details of the authorisation, including any applicable exclusions, will be communicated to you via email, provided we have your email address on record and an authorisation request has been submitted on your behalf. This information will also be shared with the hospital and, if requested, with your treating healthcare provider

Make sure to clarify any uncertainty you may have with your treating provider or the Scheme prior to your admission, as some procedures, items and medication may not be covered or you may have to pay some of the costs. Should your healthcare provider disregard the terms and conditions of the authorisation, you will remain responsible for the costs incurred.

You are covered up to 100% of the Medical Scheme Rate for in-hospital treatment. If the healthcare provider charges more than the Medical Scheme Rate, you will have to pay the difference.

Please use the medical and provider search tool to find your nearest GP or specialist.

When you need to go to hospital for a planned Prescribed Minimum Benefit (PMB) procedure or treatment

The Scheme will pay the hospital account and related healthcare providers accounts up to 100% of the Medical Scheme Rate. Specialists on the Scheme's network list will be covered up to the agreed rate. You will be responsible for the difference, if the hospital or healthcare providers charge more than the Medical Scheme Rate

Funding for a private ward is subject to a motivation from the attending practitioner and authorisation.