GENERAL EXCLUSIONS APPLICABLE TO ALL BENEFIT OPTIONS
(PMB’S NOT APPLICABLE)
1.1
1.1.1
All travel expenses for doctors and patients.
1.1.2
Medical aids, orthopaedic, surgical and medical appliances, except for those defined in Annexure B.1 to B.10 including any sub-benefit option registered.
1.1.3
Reports, examinations and tests requested for emigration, immigration, visas, insurance policies, employment, admission to schools and universities, court medical reports, muscle-function tests, fitness examinations and tests, adoption of children and retirement because of ill health.
1.1.4
Any operations, treatment and procedures for non-functional or cosmetic purposes.
1.1.5
Accounts for services rendered by persons not registered with the Health Professions Council of South Africa, Associated Health Service Professions Board or any other similar Healthcare body in the country where the service was rendered.
1.1.6
Accounts in respect of:
1.1.6.1
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 however 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 in respect of this benefit by the Scheme.
1.1.6.2
Obesity.
1.1.6.3
Appliances and medication to prevent injuries during sports and recreational activities.
1.1.6.4
Injuries arising from illegal actions on the basis of which the member or his dependants took part in a criminal offence.
1.1.6.5
Appointments not kept by members.
1.1.7
Accommodation in an old-age home or institution providing general care and nursing services to persons, e.g. the infirm aged and chronically sick patients, or similar institutions.
1.1.8
Examinations, tests and treatment of impotence and of infertility or artificial insemination or artificial fertilisation of a person within or outside the human body as defined in the National Health Act (Act 61 of 2003) (NHA) and more specifically the Regulations: general control of human bodies, tissue, blood, blood products and gametes, issued in terms of the NHA.
In the case of artificial insemination, Bestmed shall not make any contribution in respect of the preparatory expenses, i.e. pre-insemination expenses or insemination outside the female body.
1.1.9
Costs in excess of the annual maximum benefits to which the member is entitled under Bestmed’s rules.
1.1.10
Any costs in respect of conditions specifically excluded from benefits because of a waiting period at admission or registration of the member and his dependants with Bestmed.
1.1.11
The costs of holidays for recuperation purposes, accommodation in spa's, health resorts and places of rest even if prescribed by a treating provider.
1.1.12
HIV, Aids and other sexually contagious diseases: Provided that-
1.1.12.1
Services in a public hospital shall be paid, limited to the minimum benefits provided for in regulation 8 of the regulations in terms of the Medical Schemes Act (No. 131 of 1998) and Annexure D1 of these Rules; and
1.1.12.2
The member or his dependants shall furnish clinical evidence of their HIV/AIDS status to the Medical Advisor of Bestmed.
1.1.13
Costs arising from a person's association with the official armed forces for which heis covered by the Government.
1.1.14
Benefits not referred to in this Schedule or services not rendered in terms of accepted protocol or are not aimed at the treatment of an actual or supposed condition or deficiency, disadvantaging or endangering essential bodily functions.
1.1.15
Mammary surgery except where this is related to carcinoma, tumours and abscesses.
1.1.16
Refractive surgery for Pulse1. On all other benefit options where –
1.1.16.1
Hyperopia is measured greater than +3; or
1.1.16.2
Myopia is measured more negative than -5; or
1.1.16.3
Astigmatism is measured greater than - 2.5; and
1.1.16.4
Pre-Authorisation shall apply.
1.1.17
Any cost charged by a service provider for medical motivations or prior motivations as stipulated by these Rules, unless the Scheme has requested such aforestated medical motivations.
1.1.18
Costs arising from lost or damaged devices, apparatus, spectacles or contact lenses.
1.1.19
Psychometric tests.
1.1.20
Injuries during participation in riots, civil unrest or public disorder, war, invasion, any act of foreign enemies, hostilities, warlike operations or civil war.
1.1.21
The following exclusions relating to oral and dental benefits:
1.1.21.1
The cost of gold, metal or other inlays in a denture and/or crown.
1.1.21.2
Bleaching of vital teeth.
1.1.21.3
Lingual orthodontics.
1.1.22
Procedures considered by Bestmed as cosmetic or of a cosmetic approach where alternative
procedures exist.
1.1.23
Items indicated in the Dental Schedule as “by arrangement” or “N/A”.
1.1.24
Procedures requiring prior authorisation for which no authorisation was applied for.
1.1.25
Sunglasses.
1.1.26
Ambulance and emergency evacuation from a hospital to a patient’s home or from a patient’s home to a consulting room of any medical practitioner.
1.1.27
Transport fees, renting of birth pools, hospital facility fees, medical disposables and medication, antenatal consultations, doulas and breast feeding support for home confinements by a midwife and midwife assisted births in an Active Hospital Birth Unit.
1.2
The following benefits are not applicable to certain options according to the design of such an option:
1.2.1
Any out of hospital services for Beat1 members (day-to-day benefits), including non-CDL chronic medicine, acute medicine and over-the counter medicine.
1.2.2
Biological or other high cost medicine, meaning any medicinal product manufactured in or extracted from biological sources, or other high cost speciality medicines, including rational designed medicines are excluded from the Beat1, Beat2, Beat3, Beat4, Pulse1 and Pace1 benefit options.
1.2.3
Surgical dentistry for Pulse1.
1.2.4
External prosthesis for Pulse1.
1.2.5
Specialised dentistry for Pulse1.
1.2.6
Supplementary services out of hospital for Pulse1.
1.2.7
Rehabilitation after trauma for Pulse1, Pulse2 and Beat1.
1.2.8
Orthopaedic and surgical appliances during hospitalisation for Beat1.
1.2.9
Non PMB complications for breast reduction for Pace4.
1.2.10
Facility fee as part of out-of-network visits for Pulse1.
1.2.11
Specialised diagnostic imaging (MRI, Cat scans, PET scans, angiography, etc.) for Pulse1.
1.2.12
Radiology tests requested by Specialists not listed on the radiology tariff list for Pulse1.
1.2.13
Contact lenses, contact lens solutions, mirror or other graded tined lenses, accessories or enhancements for glasses for Pulse1.
1.2.14
Refractive surgery for Pulse1.
1.2.15
The following dental exclusions for Pulse2:
1.2.15.1
Orthodontic therapy for patients older than 18 years old;
1.2.15.2
Complications with removable dentures; and
1.2.15.3
MRI and CT scans for any dento-alveolar procedure.
1.3
The following is a list of exclusions as applied by CareCross and will therefore be applicable to the Pulse1 benefit option. These exclusions might be in addition to the exclusions indicated in Annexure C1.
1.3.1
Any services obtained from a non-CareCross supplier other than those covered under the “Out of Network” benefit.
1.3.2
Travel expenses.
1.3.3
Cosmetic treatment, operations, procedures and applicators, toilet preparations,etc.
1.3.4
Reports, examinations and tests for insurance policies, legal reasons.
1.3.5
Injuries arising from or appliances for professional sport, bungee or parachute jumps.
1.3.6
Accommodation in an old age home, general care in stitutions, spa’s, health or holiday resorts.
1.3.7
HIV, Aids treatment except for the general health management services as provided for in the Capitation agreement between CareCross and the Scheme.
1.3.8
Treatment for obesity, alcohol or drug abuse.
1.3.9
Treatment and operations of choice and non-essential medical items.
1.3.10
Acupuncture, biokenetics, chiropractors, herbalists, nature and homeopaths.
1.3.11
Chronic psychiatric conditions and mental disorders except for CDL conditions.
1.3.12
Treatment and medication in respect of Tuberculosis other than general health management at general practitioner level.
1.3.13
Injuries sustained during participationin strikes, illegal picketing, riots or physical struggle.
1.3.14
Nutritional supplements, tonics, stimulants, vitamins, minerals.
1.3.15
Contraceptives and devises to prevent pregnancy.
1.3.16
Stimulant laxatives.
1.3.17
Treatment for infertility and sexual dysfunction.
1.3.18
Root canal treatment and other advanced dentistry.
1.3.19
Services in respect of the treatment of any sickness condition or injury sustained by a beneficiary for which any other party may be liable.
1.3.20
Biologics not forming part of the care-cross out drug list.
1.4
Other limitations of benefits Benefits in respect of medicines obtained on prescription of a designated service provider are limited to the prescribed quantities, but in any event to not more than one month’s supply thereof.
1.5
Voluntary use of a non-DSP Should a beneficiary voluntarily choose not to make use of a Hospital DSP on the Pulse1, Pulse2 and the efficiency-discount sub-options from Beat1 up to Beat4 benefit options, a maximum co-payment of R5 000-00 will apply.
2.1
Preparations for the specific treatment of obesity, including dietary supplements.
2.2
Patent and household remedies.
2.3
Nutritional supplements (including patent and baby foods).
2.4
Medicines used specifically to treat infertility.
2.5
Aphrodisiacs,
2.6
Sun-screening agents (medicated or otherwise).
2.7
All soaps and shampoos (medicated or otherwise).
2.8
Cosmetic substances.
2.9
Anti-habit substances.
2.10
Anabolic steroids.
2.11
Tonics, stimulants, biological substances, vitamins, minerals and vitamin/mineral combinations unless proven medical indications can be submitted: Provided that Bestmed will contribute for prenatal medicine.
2.12
Unregistered medicines will not be considered for benefits until such time that it is registered by the Medicines Control Council.
2.13
Unregistered indications or “off label” use of medicines will not be considered for benefits.
2.14
Haematinics i.e. Erythropoietin for Pulse
1.2.15
Biological and Biotechnological substances for Pulse1.
3.1
The maximum benefits to which a member and his dependants are entitled in any financial year are limited as set out in Annexure B1 to B10 including any sub-benefit options registered.
3.2
Members admitted during the course of a financial year are entitled to the benefits adjusted in proportion to the period of membership calculated from the date of
admission to the end of the particular financial year.
3.3
Unless otherwise decided by the Board of Trustees, benefits in respect of medicines obtained on a prescription are limited to one month’s supply for every such prescription or repeat thereof.
|
