Additional Ronbel Gap Cover Products

Transcription

1 1 Additional Ronbel Gap Cover Products

2 Gap Cover Ronbel Gap Cover Products 2013 Charges above the Medical Scheme Tariff for services in-hospital and/or the necessity for chemotherapy or radiotherapy for the treatment of cancer on an out-patient basis and/or the necessity for kidney dialysis on an out-patient basis, limited to 5 times the Medical Scheme Tariff and R1 000,000 per family per annum. It is important to note that Gap Cover does not provide for charges above the tariff for hospital costs, prosthesis and medication. The only cover is provided for the services provided by Specialists, General Practitioners and medical professionals such as physiotherapists for the period of hospitalisation. Conditions: A 3 month waiting period and exclusions on pre-existing conditions applies to individuals, members on voluntary participation groups and members of small employer groups (20 or less employees). A 12 month pre-existing condition clause applies. A lifetime exclusion on pre-existing conditions applies to biological cancer drugs Maximum age of entry is 65 years of age. The above conditions apply to all the Gap Cover products from entry level to plus level 4. Very Important Entry level Gap Cover DOES NOT COVER CLAIMS FOR CO-PAYMENTS. A copayment can be better described as an excess (same as in car insurance) charged to you by your medical scheme for certain in-hospital procedures. You as the medical scheme holder are responsible for these co-payments. 2

3 Additional Products There are four additional Gap Cover Products which are not specifically designed for Naptosa members as they do not have an attachment point to the Principle Insured s medical aid scheme. It is important to note that the Gap Cover as described in the Naptosa Gap Cover Brochure in its entirety also applies to these four Gap Cover Products listed below in order that Naptosa members can make an informed decision as to which product will best suit their needs: 1) Gap Plus Level 1 R per month Gap Cover and Hospital Co-payment/Deductible Cover Gap Cover plus; Charges above the Medical Scheme Tariff for services in-hospital and/or the necessity for chemotherapy or radiotherapy for the treatment of cancer on an out-patient basis and/or the necessity for kidney dialysis on an out-patient basis, limited to 4 times the Medical Scheme Tariff and R per insured person per annum and R per family per annum. As from 01 January 2012 the limit will increase to 5 times the Medical Scheme Tariff and the overall limitation to R per family per annum. Charges in the form of a co-payment or deductible applied for inhospital admissions and/or the necessity for chemotherapy or radiotherapy for the treatment of cancer on an out-patient basis, and/or the necessity for kidney dialysis on an out-patient basis. Such co-payments or deductible amounts applied are as per the rules of the Principle s registered medical scheme. Benefits for co-payments or deductibles are limited to R per insured person per annum and R per family per annum. 3

4 A 3 month waiting period and exclusions on pre-existing conditions apply to individual members on voluntary participation groups and members of small employer groups (20 or less employees). 12 month pre-existing condition clause applies. A strict clause excluding any form of pre-existing cancer will be applied to the benefit providing biological drugs. Maximum age of entry is 65 years of age. Where a member has an Ambledown Gap Cover policy or similar policy provided by another insurer, the waiting periods and preexisting conditions will be waived if completed, alternatively the balance of the waiting period and the pre-existing conditions from the previous Gap Cover policy will be carried over to the new Gap Cover policy. Gap Cover does not provide for charges above the tariff for hospital costs, prosthesis and medication. Gap Cover is provided for the services provided by Specialists, General Practitioners and Medical Professionals, such as physiotherapists, for the period of hospitalisation. 2) Gap Plus Level 2 R per month Gap Cover and major Medical Co-payment/Deductible Cover Gap Cover plus; Charges above the Medical Scheme Tariff for services in-hospital and/or the necessity for chemotherapy or radiotherapy for the treatment of cancer on an out-patient basis and/or the necessity for kidney dialysis on an out-patient basis, limited to 4 times the Medical Scheme Tariff and R per insured person per annum and R per family per annum. As from 01 January 4

5 2012 the limit will increase to 5 times the Medical Scheme Tariff and the overall limitation to R per family per annum. Charges in the form of a co-payment or deductible applied for inhospital admissions and/or the necessity for chemotherapy or radiotherapy for the treatment of cancer on an out-patient basis, and/or the necessity for kidney dialysis on an out-patient basis. Charges in the form of a co-payment or deductible for major outpatient treatments limited to specialized diagnostic radiology limited to MRI and CT scans. Such co-payments or deductible amounts applied are as per the rules of the Principles registered medical scheme. Benefits for co-payments or deductibles are limited to R per insured person per annum and R per family per annum. A 3 month waiting period and exclusions on pre-existing conditions applies to individual members on voluntary participation groups and members of small employer groups (20 or less employees). 12 month pre-existing condition clause applies. A strict clause excluding any form of pre-existing cancer will be applied to the benefit providing biological drugs. Maximum age of entry is 65 years of age. Where a member has an Ambledown Gap Cover policy or similar policy provided by another insurer, the waiting periods and preexisting conditions will be waived if completed, alternatively the balance of the waiting period and the pre-existing conditions from the previous gap Cover policy will be carried over to the new Gap Cover policy. Gap Cover does not provide for charges above the tariff for hospital costs, prosthesis and medication. 5

6 Gap Cover is provided for the services provided by Specialists, General Practitioners and Medical Professionals such as physiotherapists for the period of hospitalisation. 3) Gap Plus Level 3 R per month Hospital Co-payment, deductible and Sub-limitation Cover Gap Cover plus; Charges above the Medical Scheme Tariff for services in-hospital and/or the necessity for chemotherapy or radiotherapy for the treatment of cancer on an out-patient basis and/or the necessity for kidney dialysis on an out-patient basis, limited to 4 times the Medical Scheme Tariff and R per insured person per annum and R per family per annum. As from 01 January 2012 the limit will increase to 5 times the Medical Scheme Tariff and the overall limitation to R per family per annum. Charges in the form of a co-payment or deductible applied for inhospital admissions and/or the necessity for chemotherapy or radiotherapy for the treatment of cancer on an out-patient basis, and/or the necessity for kidney dialysis on an out-patient basis. Charges in the form of a co-payment or deductible for major outpatient treatments limited to specialized diagnostic radiology limited to MRI and CT scans. Charges above any sub-limitation imposed by the medical scheme for in-hospital admissions. Such co-payment or deductible and/or sub-limitation amount applied are as per the rules of the Principle s registered medical scheme. No benefit is paid on any sub-limitation for a condition that is listed as a prescribed minimum benefit. 6

7 Sub-limitation cover is limited to R30,000 in the aggregate per insured person per annum. Benefits for co-payments or deductibles are limited to R30,000 per insured person per annum and R50,000 per family per annum. A 3 month waiting period and exclusions on pre-existing conditions applies to individual members on voluntary participation groups and members of small employer groups (20 or less employees). 12 month pre-existing condition clause applies. A strict clause excluding any form of pre-existing cancer will be applied to the benefit providing biological drugs. Maximum age of entry is 65 years of age. Where a member has an Ambledown Gap Cover policy or similar policy provided by another insurer, the waiting periods and preexisting conditions will be waived if completed, alternatively the balance of the waiting period and the pre-existing conditions from the previous Gap Cover policy will be carried over to the new Gap Cover policy. Gap Cover does not provide for charges above the tariff for hospital costs, prosthesis and medication. Gap Cover is provided for the services provided by Specialists, General Practitioners and Medical Professionals such as physiotherapists for the period of hospitalisation. 3) Gap Plus Level 4 R per month Hospital Co-payments, Deductible and Sub-limitation Cover Gap Cover plus; 7

8 Charges above the Medical Scheme Tariff for services in-hospital and/or the necessity for chemotherapy or radiotherapy for the treatment of cancer on an out-patient basis and/or the necessity for kidney dialysis on an out-patient basis, limited to 4 times the Medical Scheme Tariff and R per insured person per annum and R per family per annum. As from 01 January 2012 the limit will increase to 5 times the Medical Scheme Tariff and the overall limitation to R per family per annum. Charges in the form of a co-payment or deductible applied for inhospital admissions and/or the necessity for chemotherapy or radiotherapy for the treatment of cancer on an out-patient basis, and/or the necessity for kidney dialysis on an out-patient basis. Charges in the form of a co-payment or deductible for major outpatient treatments limited to specialized diagnostic radiology limited to MRI and CT scans. Charges above any sub-limitation imposed by the medical scheme for in-hospital admissions. The sub-limitation imposed by the medical scheme for biological cancer drugs, limited to Herceptin, Mylotarg, Nexavar, Gleevec, Sprycel, Faslodex, Velcade, Tarceva, Alimta, Zevalim, Avastin, Erbitux, Sutent, Fludara, Mabthera, with specific oncological condition and/or specific sub-groups of cancers limited to subgroups of the following categories: o HER 2 + breast cancer o Acute myeloid leukaemia o Advanced hepatocellular carcinoma o Acute lymphoblastic leukaemia o Chronic myeloid leukaemia o Chronic lymphocytic leukaemia o Hairy cell leukaemia o Myelodysplasia 8

9 o HER-ve breast cancer o Gastrointestinal stromal tumour o Mulitple myeloma o Non small cell lung cancer o Non hodkins lymphoma o Metastic colorectal cancer o Advanced renal cell carcinoma o Head and neck cancer Such co-payment or deductible and/or sub-limitation amounts applied are as per the rules of the principle s registered medical scheme. No benefit is paid on any sub-limitation for a condition that is listed as a prescribed minimum benefit. A strict clause excluding any form of pre-existing cancer will be applied for the benefit providing for cancer drugs. Biological Cancer Drug treatment cover (sub-limitation) is limited to R200,000 per insured person per annum. Sub-limitation cover is limited to R30,000 in the aggregate per insured person per annum (other than biological drugs). Benefits for co-payments or deductibles are limited to R per insured person per annum and R per family per annum. A 3 month waiting period and exclusions on pre-existing conditions applies to individual, members on voluntary participation groups and members of small employer groups (20 or less employees). 12 month pre-existing condition clause applies. A strict clause excluding any form of pre-existing cancer will be applied to the benefit providing biological drugs. Maximum age of entry is 65 years of age. Where a member has an Ambledown Gap Cover policy or similar policy provided by another insurer, the waiting periods and pre- 9

10 existing conditions will be waived if completed, alternatively the balance of the waiting period and the pre-existing conditions from the previous Gap Cover policy will be carried over to the new Gap Cover policy. Gap Cover does not provide for charges above the tariff for hospital costs, prosthesis and medication. Gap Cover is provided for the services provided by Specialists, General Practitioners and Medical Professionals such as physiotherapists for the period of hospitalisation. Claiming Procedure 1) Claims must be submitted within 6 months of procedure date. 2) The underwriter shall not be liable in respect of any claims submitted outside the 6 month of procedure date period. 3) Completed & signed claim form, medical aid statement reflecting the gap claim and all related accounts i.e. specialist, general practitioner etc. must be forwarded to Memp Financial Services (Pty) Ltd for checking. 4) Memp Financial Services (Pty) Ltd will forward your claim to the administration company for processing. 5) Claim forms are also available from ronbelss@gmail.com. 10

11 Enquiries Contact details for claims are as follows: Tel. : Cell. (Colin) : Cell. (Jon) : Fax : ronbelss@gmail.com Postal Address : 8 Main Road Walmer Port Elizabeth 6070 This brochure is for information purposes only. All claims are subject to the Master Policy Document. Statutory Notice to Short Term Policy Holders Important Please read carefully Disclosures and other legal requirements (This notice does not form part of the Insurance Contract or any other document) As a short term insurance policy holder or prospective policy holder, you have the right to the following information: 1) About the Insurer Name: Constantia Insurance Company Limited Physical Address: Unit 2 Tulbagh, 360 Oak Avenue, Randburg, 2194 Postal Address: P.O. Box 3518, Cramerview, 2060 Telephone Number: Fax Number: Compliance Company: Moonstone Information Refinery (Pty) Ltd:

12 Complaint Process: Any complaints in terms of the failure of Constantia Insurance Company Limited or your insurance broker to comply with the terms of the Policy Holder Protection Rules should be lodged in writing to the Compliance Officer of Constantia Insurance Company Limited. If such complaint is not resolved to your satisfaction, you may refer your complaint in writing to: Registrar of Short Term Insurance Financial Services Board P.O. Box Menlo Park 0102 Telephone Number: Fax Number: Any claim problems which are not satisfactorily resolved by the insurance intermediary and/or Constantia Insurance Company Limited may be referred to: The Ombudsman for Short Term Insurance P.O. Box Braamfontein 2017 Telephone Number: Fax Number: ) Broker Commission In terms of the Short term Act an intermediary is entitled to 12.5% commission on motor insurance and 20% for any other class of business. 3) Agreement Constantia Insurance Company Limited has an agreement with Ambledown Risk and Underwriting Managers (Pty) Ltd to act as an independent intermediary for all policy holders introduced to Constantia Insurance Company Limited, by its appointed brokers. 12