NETCARE MEDICAL SCHEME RULES BENEFIT YEAR 2016 PREPARED BY THE BOARD OF TRUSTEES SEPTEMBER 2015 REGISTRATION NUMBER 1584

Transcription

1 NETCARE MEDICAL SCHEME RULES BENEFIT YEAR 2016 PREPARED BY THE BOARD OF TRUSTEES SEPTEMBER 2015 REGISTRATION NUMBER 1584

2 Table of Contents 1. NAME LEGAL PERSONA REGISTERED OFFICE DEFINITIONS OBJECTIVES MEMBERSHIP REGISTRATION AND DE-REGISTRATION OF DEPENDANTS TERMS AND CONDITIONS APPLICABLE TO MEMBERSHIP TRANSFER OF EMPLOYER GROUPS TO AND FROM OTHER MEDICAL SCHEMES MEMBERSHIP CARD AND CERTIFICATE OF MEMBERSHIP CHANGE OF ADDRESS/BANKING DETAILS OF MEMBER SUSPENSION AND TERMINATION OF MEMBERSHIP CONTRIBUTIONS LIABILITIES OF EMPLOYER AND MEMBER CLAIMS PROCEDURE BENEFITS PAYMENT OF ACCOUNTS GOVERNANCE DUTIES OF BOARD OF TRUSTEES POWERS OF BOARD DUTIES OF PRINCIPAL OFFICER AND STAFF INDEMNIFICATION & FIDELITY GUARANTEE FINANCIAL YEAR OF THE SCHEME BANKING ACCOUNT AUDITOR & AUDIT COMMITTEE... 30

3 26. GENERAL MEETINGS VOTING AT MEETINGS COMPLAINTS AND DISPUTES TERMINATION OR DISSOLUTION AMALGAMATION AND TRANSFER OF BUSINESS RIGHT TO OBTAIN DOCUMENTS AND INSPECTION OF DOCUMENTS AMENDMENT OF RULES ANNEXURE A NETCARE SAVINGS OPTION CONTRIBUTIONS ANNEXURE B NETCARE SAVINGS OPTION BENEFIT SCHEDULE ANNEXURE C EXCLUSIONS ANNEXURE D MEMBER SAVINGS ACCOUNTS (MSA) ANNEXURE E MEDICINE BENEFIT IN RESPECT OF CHRONIC CONDITIONS ANNEXURE F PRESCRIBED MINIMUM BENEFITS... 50

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5 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e 5 1. NAME The name of the Scheme is the Netcare Medical Scheme, hereinafter referred to as the Scheme. The abbreviated name is NMS. 2. LEGAL PERSONA The Scheme, in its own name, is a body corporate, 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 the Medical Schemes Act, No. 131 of 1998, the Regulations promulgated in terms thereof and these Rules. 3. REGISTERED OFFICE The registered office of the Scheme is situated at 76 Maude Street Sandton 2196 but the Board may transfer such office 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-: i. a word or expression in the masculine gender includes the feminine; ii. a word in the singular number includes the plural, and vice versa; and iii. the following expressions have the following meanings: 4.1 "Act", the Medical Schemes Act, 1998 (Act No. 131 of 1998), and the Regulations framed there under. 4.2 "Admission Date", shall mean: in respect of an Employer, the date on which the contract between the Scheme and the Employer becomes operative;

6 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e in respect of a Member, the date on which he becomes a member; in respect of a Dependant, the date upon which such Dependant is registered as a Dependant in terms of the Rules. 4.3 Adult Dependant, shall mean a person who has reached the age of 21 to whom the member is factually liable for family care and support, who is not covered under the Child Dependant definition. 4.4 Annual Limit, shall mean the maximum Benefit to which a Member or Dependant is entitled in terms of the Rules during each Financial Year. 4.5 Approval", prior written approval. 4.6 "Auditor", an auditor registered in terms of the Public Accountants' and Auditors' Act. 1991, (Act No. 80 of 1991). 4.7 "Beneficiary, a member or a person admitted as a dependant of a member. 4.8 "Benefits", shall mean the amount/s payable in terms of the Rules, whether for himself, in respect of his Dependant or to a supplier of service. 4.9 "Board", the Board of Trustees constituted to manage the Scheme in terms of these Rules "BHF", The Board of Healthcare Funders of Southern Africa Calendar month, means a period of time consisting of thirty days in April, June, September and November, and of thirty-one days in the remainder of the months, except February, which consists of twenty-eight days, except in leap-year, when the intercalary day is added, making twenty-nine days Child Dependant", a member s natural child, or a stepchild or legally adopted child or a child in the process of being legally adopted or a child who has been placed in the custody of the member or his/her spouse or partner and who is not a beneficiary of any other medical scheme and,

7 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e under the age of 21, or having been born into the Scheme in a handicapped condition or having become handicapped whilst he or she is a child dependant, is permitted by the Board in its sole discretion to be treated under the Rules as a Child dependant after reaching the age of For children over the age of 21 years that are in capacity registered as students with acceptable tertiary institutions, on receipt of proof of registration from the facility the student will be charged child rates. This will only be applicable up to the age of 25 years "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 "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 Contracted fee, the fee determined in terms of an agreement between the Scheme and a service provider or relevant health service providers in respect of payment "Contribution", in relation to a member, the amount, exclusive of interest, paid by or in respect of the member and his/her registered dependants as membership fees "Cost, in relation to a benefit, the net amount payable in respect of the service rendered or material obtained Creditable coverage means any period during which a late joiner was: a member or a dependant of a medical scheme; a member or a dependant of an entity doing the business of a medical scheme which at the time of his membership of such entity was exempt from the provisions of the Act.

8 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e "Dependant", a member s spouse or partner who is not a member or a registered dependant of a member of a medical scheme; a member s dependent child; in the case of mental or physical disability the dependant may apply to be considered as a child dependant; the immediate family of a member in respect of whom the member is liable for family care and support any other person who is recognised by, and at the discretion of, the Board as a dependant for purposes of these Rules Immediate family member A member s spouse or life partner and any child born from their liaison; Any other child of the member or his spouse or life partner A grandchild or parent of the member or his spouse or life partner "Dependant qualification", in relation to a dependant other than the member s spouse or partner a dependant that is financially reliant on the member, the Scheme may request support in evidence of financial dependency. False information will result in membership to the Scheme being terminated Designated service provider, a healthcare provider or group of health care providers selected by the Scheme as its preferred service provider or providers to provide relevant health care services to its members Dispensing Fee, means the fee that a pharmacist or a person licensed to dispense medicines may charge to dispense medicines as contemplated and regulated in terms of the Medicines and Related Substances Act,1965 (Act No. 101 of 1965) as amended Emergency medical condition, the sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person s life at serious risk "Employee", a person in the employment of the Employer.

9 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e "Employer", Netcare Limited and any subsidiary of the Group "General waiting period", a period in which a beneficiary is not entitled to claim any benefits "Income", for the purposes of calculating contributions in respect of a member who is an employee - his rate of pay will apply; a member who registers his spouse or partner as a dependant, the higher of his or his spouse's or partner's rate of pay will determine the contribution in the event that the member and his spouse or partner are both employees of Netcare Limited and any subsidiary; a continuation member 50% of the member s pre-retirement rate of pay and in respect of widows, widowers and orphans 50% of the deceased principal member s rate of pay immediately prior to his death. This percentage will be reviewed on a 3- yearly basis to ensure the Scheme is not adversely impacted "Late joiner", may be implemented by the Scheme. A member has 30 days from joining the Group to apply for medical aid membership, failing which late joiner penalties may be imposed as per the Medical Schemes Act. A member s dependants may also have late joiner penalties applied if they have had no previous continuous medical scheme membership "Member", any person who is registered as a member of the Scheme in terms of these rules "Member family", the member and all his registered dependants Notice, shall mean any communication from the Scheme including but not limited to, membership statements, tax certificates, arrears, suspension and termination letters, any other general communication pertaining to the Scheme, it benefits, rules and service providers that may be applicable "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/or a shared and common household, irrespective of the sex of either party.

10 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e Penalty band, shall mean the applicable penalty band to be applied to a late joiner in terms of the first column of the table in terms of Scheme rule The following formula shall be applied: A = B minus (35 + C) where: A means the number of years referred to in the first column of the table for purposes of determining the appropriate penalty band; B means the age of the late joiner at the time of his or her application for membership or admission as a dependant; and C means the number of years of creditable coverage which can be demonstrated by the late joiner "Prescribed minimum benefits", the benefits contemplated in section 29(1) (O) of the Act and consist of the provision of the diagnosis, treatment and care costs of the Diagnosis and Treatment Pairs listed in Annexure A of the regulations, subject to any limitations specified therein; and any emergency medical condition the 26 chronic conditions (defined in the Chronic Disease List) "Prescribed minimum benefit condition", a condition contemplated in the Diagnosis and Treatment Pairs listed in Annexure A of the Regulations, any emergency medical condition or a condition detailed in the Chronic Disease List "Pre-existing Sickness Condition", shall mean 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 "Preferred Provider", a provider of a relevant health service nominated by the Scheme and paid for his services as determined by the Scheme "Pre-authorisation", the prior authorisation by the Medical Assessor on behalf of the Scheme of the rendering of a relevant health service to a Beneficiary.

11 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e "Public Healthcare System", means the entire system of hospitals of each provincial government of the Republic of South Africa and includes any necessary transfer to a public hospital outside the province of residence for specialist treatment not available in the province of residence "Registrar", the Registrar or Deputy Registrar of Medical Schemes appointed in terms of section 18 of the Act "Single Exit Price" or "SEP", means the price set by the manufacturer or importer of a medicine or scheduled substance, combined with the logistics fee and VAT, as regulated in terms of the Medicines and Related Substances Act,1965 (Act No. 101 of 1965) as amended "Spouse", the person to whom the member is married in terms of any law or custom "Supplier", shall mean a person who supplies a relevant health service "Netcare Medical Scheme Tariff" or "NMS Tariff", is equivalent to: The negotiated rate for hospitals and designated service providers and referred to in the Rules as 100% of NMS tariff at DSP; or The negotiated rate for preferred providers referred to in the Rules as 100% of NMS tariff at Preferred Provider; or An inflation-adjusted version of the 2006 National Health Reference Price List for health care services published by the Council for Medical Schemes as indicated below and referred to as 100% of NMS tariff: % % % % % % % % %

12 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e % The dispensing fee for medicines as negotiated with the Scheme s designated or preferred service providers Single exit price - the price of a specific drug, determined annually by the Department of Health The amount pre-authorised by the Scheme and referred to in the Rules as 100% of approved benefit. 5. OBJECTIVES 5.1 The objectives of the Scheme are to undertake liability, in respect of its members and their dependants, in return for a contribution: To make provision for the obtaining of any relevant health service; To grant assistance in defraying expenditure incurred in connection with rendering of any relevant service; and/or 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. 6. MEMBERSHIP 6.1 Eligibility Subject to Rule 8, membership of the Scheme is restricted to employment and/or former employment of the member by the employer or his predecessor or successor in title, as defined in these rules, and is either voluntary or compulsory, depending on the employee's conditions of employment. 6.2 Retirees A member who retains his membership of the Scheme in the event of his retiring from the service of his employer or his employment being terminated by his employer on account of age, ill-health or other disability.

13 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e The Scheme must inform the member of his right to continue his membership and of the contribution payable from the date of retirement or termination of his employment. Unless such member informs the Board in writing of his desire to terminate his membership, he continues to be a member Rules relating to company subsidy are not under the control of the Scheme and as such all queries and disputes regarding this will have to be dealt with by the Employer and its appointed staff A Continuation member who retains his membership of the Scheme in terms of Rule 6.2 and his Dependants shall cease to be eligible for new or continued Membership of the Scheme, in the event of the Scheme terminating Membership as a result of non-payment of contributions as provided for under Rule A Continuation member who retains his membership of the Scheme in terms of Rule 6.2 who voluntarily resigns from the Scheme for any reason whatsoever shall cease to be eligible for new or continued Membership of the Scheme, together with his Dependants. 6.3 Dependants of deceased members The dependants of a deceased member who are registered with the Scheme as his dependants at the time of such member s death are entitled to continue with membership of the Scheme without any new restrictions, limitations or waiting periods The Scheme must inform the dependant of his right to membership and of the contributions payable in respect thereof. Unless such person informs the Board in writing of his intention not to become a member, he must be admitted as a member of the Scheme If a Member dies, his surviving spouse shall be deemed to be the Member of the Scheme and the Member s Dependants registered as at the date of the Member s death shall be deemed to be the Dependants of such a surviving spouse until such time that they would no longer have been an eligible Dependant of the deceased Member as defined in the Rules In the event that a Member dies and leaves no spouse or partner, the eldest of the remaining beneficiaries, which may be a Child Dependant, shall be substituted as the Member while the status of the other Dependants remains unaffected until he would no longer have been an eligible Dependant of the deceased Member as defined in the Rules Such a member s membership terminates if he becomes a member or a dependant of a member of another medical scheme.

14 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e The widowed Spouse or partner of a deceased Employee who was not a Dependant prior to his or her death shall not be eligible to Membership of the Scheme A person who becomes the Member in terms of Rule or and their Dependants shall cease to be eligible for new or continued Membership of the Scheme, in the event of the Scheme terminating Membership as a result of non-payment of contributions as provided for under Rule A person who becomes the Member in terms of Rule or who voluntarily resigns from the Scheme for any reason whatsoever shall cease to be eligible for new or continued Membership of the Scheme, together with his Dependants. 7. REGISTRATION AND DE-REGISTRATION OF DEPENDANTS 7.1 Registration of Dependants A member may apply for the registration of his dependants at the time that he applies for membership in terms of Rule If a member applies to register a new born, newly adopted child, child placed in custody or in the process of being adopted within 30 (thirty) days of the date of birth or adoption, such child shall thereupon be registered by the Scheme as a dependant. Increased contributions shall then be due as from the first day of the month of birth or adoption and benefits will accrue as from the date of birth or adoption If a member who marries subsequent to joining the Scheme applies within 30 days of the date of such marriage to register his spouse as a dependant, his spouse shall thereupon be registered by the Scheme as a dependant. Increased contributions shall then be due as from the first day of the month of marriage and benefits will accrue as from the date of marriage If a member enters into a relationship akin to a marriage subsequent to joining the Scheme, he may apply within 30 days of such relationship to register his partner as a dependant. Increased contributions shall then be due as from the first day of the month in which the shared common household commenced and benefits will accrue as from the date the shared common household commenced. 7.2 De-registration of Dependants

15 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e A member shall inform the Scheme within 30 days of the occurrence of any event which results in any one of his dependants no longer satisfying the conditions in terms of which he may be a dependant When a dependant ceases to be eligible to be a dependant, he shall no longer be deemed to be registered as such for the purpose of these Rules or entitled to receive any benefits, regardless of whether notice has been given in terms of these Rules or otherwise. 8. TERMS AND CONDITIONS APPLICABLE TO MEMBERSHIP 8.1 A minor may become a member with the consent of his parent or guardian. 8.2 No person may be a member or a dependant of a member of more than one registered medical scheme or claim or accept benefits in respect of himself or any of his dependants from any medical scheme in relation to which he is not a member. 8.3 Prospective members shall, prior to admission, complete and submit the application forms required by the Scheme, together with satisfactory evidence in respect of himself and his dependants of age, income, state of health and of any prior membership or admission as a dependant of any other medical scheme. The Scheme may require an applicant to provide the Scheme with a medical report in respect of a condition for which medical advice, diagnosis, care or treatment was recommended or received within the period of 12 months, ending on the date on which application for membership to the Scheme was made. The costs of any medical tests or examinations required to provide such medical report will be paid for by the Scheme. The Scheme may however designate a provider to conduct such tests or examinations. 8.4 The registered dependants of a member must participate in the same benefit option as the member. 8.5 Every member will, on admission to membership, receive a detailed summary of these Rules which must include contributions, benefits, limitations, rights and obligations. Payment of any contribution is deemed to constitute the member's acknowledgement that he is, on behalf of himself and his dependants, bound by these Rules and by any amendment thereto. 8.6 A member may not cede, transfer, pledge or hypothecate or make over to any third party any claim, or part of a claim or any right to a benefit which he may have against the Scheme. The Scheme may withhold, suspend or discontinue the payment of a benefit to which a member is entitled under these Rules, or any right in respect of such benefit or payment of such benefit to

16 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e 16 such member, if a member attempts to assign or transfer, or otherwise cede or to pledge or hypothecate such benefit. 8.7 Waiting periods The Scheme may impose upon a person in respect of whom an application is made for membership or admission as a dependant, and who was not a beneficiary of a medical scheme for a period of at least 90 days preceding the date of application: a general waiting period of up to three months; and a condition-specific waiting period of up to 12 months, where applicable; the waiting periods specified in and also apply in respect of any treatment or diagnostic procedures covered within the prescribed minimum benefits The Scheme may impose upon any person in respect of whom an application is made for membership or admission as a dependant, and who was previously a beneficiary of a medical scheme for less than 24 months, terminating less than 90 days immediately prior to the date of application, a waiting period that is as follows: a condition-specific waiting period of up to 12 months, except in respect of any treatment or diagnostic procedures covered within the prescribed minimum benefits; and where the previous medical scheme had imposed a general or condition-specific waiting period, and such waiting period had not expired at the time of termination, a general or condition-specific waiting period for the unexpired duration of such waiting period imposed by the former medical scheme The Scheme may impose upon any person in respect of whom an application is made for membership or admission as a dependant, and who was previously a beneficiary of a medical scheme for a continuous period of more than 24 months terminating less than 90 days immediately prior to the date of application a waiting period as follows: , a general waiting period of up to three months, except in respect of any treatment or diagnostic procedures covered within the prescribed minimum benefits The Scheme will not impose waiting periods on a person in respect of whom application is made for membership or admission as a dependant, and who was previously a beneficiary of a medical scheme, terminating less than 90 days immediately prior to the date of application, where the transfer of membership is required as a result of: change of employment; and/or

17 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e a child dependant born during the period of membership and registered within 30 days of birth/adoption; and/or addition of a spouse/partner within 30 days of marriage/proof of common household. 9. TRANSFER OF EMPLOYER GROUPS TO AND FROM OTHER MEDICAL SCHEMES If the members of a medical scheme who are members of that scheme by virtue of their employment by a particular employer, terminate their membership of such scheme with the object of obtaining membership of this Scheme, the Board will admit as a member, without a waiting period any member of such first-mentioned scheme who is a continuation member by virtue of his past employment by the particular employer and register as dependant, any person who has been a registered dependant of such employee of the particular employer. 10. MEMBERSHIP CARD AND CERTIFICATE OF MEMBERSHIP 10.1 Every member will be furnished with a membership card, containing such particulars as may be prescribed. This card must be exhibited to the supplier of a service on request. It remains the property of the Scheme and must be returned to the Scheme or destroyed on termination of membership The utilisation of a membership card by any person other than the member or his registered dependants, with the knowledge or consent of the member or his dependants, is not permitted and is construed as an abuse of the benefits of the Scheme On termination of membership or on de-registration of a dependant, the Scheme will, within 30 days of such termination or at any time on request, furnish such person with a certificate of membership cover, containing such particulars as may be prescribed. 11. CHANGE OF ADDRESS/BANKING DETAILS OF MEMBER 11.1 A Member s postal or residential address on his application form shall be deemed to be his domicillum citandi et executandi.

18 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e A notice sent by registered post to the Member at his postal or residential address shall be deemed to have been received by the Member on the seventh (7 th ) day after the date of posting. 11.3Notices may also be sent by the Scheme to a Member s nominated cell phone number, address or where an address has not been provided, to the dedicated address of the Member provided by the Employer; such notice shall be deemed to have reached the Member upon successful transmission thereof A Member must notify the Scheme in writing within thirty (30) days of any change of contact/banking details on the prescribed documentation of the Scheme. The Scheme shall not be held liable if a Member s rights are prejudiced or forfeited as a result of neglect to comply with the requirements of this Rule. 12. SUSPENSION AND TERMINATION OF MEMBERSHIP 12.1 Resignation A member who, in terms of his conditions of employment is required to be a member of the Scheme, may not terminate his membership while he remains an employee without the prior written consent of his employer Subject to any provision to the contrary contained in the Rules, a member who resigns from the service of the participating employer shall, on the date of such termination, cease to be a member and all rights to benefits shall thereupon cease, except for claims in respect of services rendered prior thereto Voluntary termination of membership A member, who, in terms of his conditions of employment is a voluntary member of the Scheme, may terminate his membership while he remains an employee Such member may terminate his membership of the Scheme using the prescribed documentation of the Scheme giving one calendar month's written notice. All rights to benefits cease after the last day of the notice month Such notice period will be waived in substantiated cases where membership of another medical scheme is compulsory as a result of a condition of employment.

19 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e Death - Membership of a member terminates on his death. The Dependants of a deceased Member may remain as Beneficiaries of the Scheme, subject to Rule Failure to pay amounts due to the Scheme - If a member fails to pay amounts due to the Scheme, his membership may be suspended or terminated as provided in these Rules Abuse of privileges, false claims, misrepresentation and non-disclosure of factual information - The Board may exclude from benefits or terminate the membership of a member or dependant whom the Board finds guilty of abusing the benefits and privileges of the Scheme by presenting false claims or making a material misrepresentation or non-disclosure of factual information. In such event he may be required by the Board to refund to the Scheme any sum which, but for his abuse of the benefits or privileges of the Scheme, would not have been disbursed on his behalf. 13. CONTRIBUTIONS 13.1 The total monthly contributions payable to the Scheme by or in respect of a member are as stipulated in Annexure A. It shall be the responsibility of the member to notify the Scheme of changes in income that may necessitate a change in contribution in terms of Annexure A hereto. The Board may from time to time change the income bands reflected in Annexure A in any particular year in accordance with the provisions and processes contemplated by the Act In addition to the contributions in Annexure A, the scheme may impose contribution penalties in respect of persons over the age of 35 years, who are enrolled as members or adult dependants and who were without creditable coverage. The premium penalties for persons joining late in life shall not exceed the following bands for the period indicated hereunder: Penalty Bands Maximum penalty 1 4 years 5% (0.05 x relevant contribution as per Annexure A) 5 14 years 25% (0.25 x relevant contribution as per Annexure A) years 50% (0.50 x relevant contribution as per Annexure A) 25 + years 75% (0.75 x relevant contribution as per Annexure A)

20 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e Contributions shall be paid monthly in arrears by not later than the 3 rd day of the succeeding month. The full monthly contribution shall be payable regardless of the number of days for which the Member and any Dependant participated in the Scheme during the relevant month. Where contributions have not been paid by the due date, they shall be in arrears and the Scheme shall have the right to suspend all benefit payments which have accrued to such member after date of default, and to give the member and/or employer written notice that if contributions are not paid up to date within fourteen (14) days of such notice, membership may be cancelled. Such notice may be given by personal delivery, registered post, telegram or e- mail In the event that contribution payments are brought up to date, prior to cancellation in terms of Rule 13.3, benefits shall be reinstated without any break in continuity. If contributions are not brought up to date, no benefits shall be due to the member from the date such contributions were due and any benefit paid after such date may be recovered by the Scheme A member shall be liable to pay any amount becoming due by him to the Scheme immediately on receipt of a notice from the Scheme setting out the amount due. Payment shall be made to such place and in such manner as the Scheme shall, from time to time, determine. A member shall be in arrears with his payment of amounts due if payment is not received in full by the Scheme; In the case of a member whose payment is deducted from his remuneration by his Employer or direct payors, within 30 days of the date upon which payment was due If payment of any amount in respect of a member is in arrears, the Scheme shall have the right to suspend all benefits which may have accrued to such member after date of default, and to give the member and/or Employer notice that if the amount is not brought up to date within 14 days membership may be cancelled. Such notice may be given by personal delivery or registered post Unless specifically provided for in the Rules in respect of savings accounts, no refund of any assets of the Scheme or any portion of a contribution shall be paid to any person where such member s membership or cover in respect of any dependant terminates during the course of a calendar month The balance standing to the credit of a member in terms of his self-insured option or savings account, at all times remain the property of the member. 14. LIABILITIES OF EMPLOYER AND MEMBER

21 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e The liability of the employer towards the Scheme is limited to any amounts payable in terms of any agreement between the employer and the Scheme The liability of a member is limited to the amount of his unpaid contributions together with any sum disbursed by the Scheme on his behalf or on behalf of his dependants which has not been repaid to the Scheme In the event of a member ceasing to be a member, any amount still owing by such member is a debt due to the Scheme and recoverable by it. 15. CLAIMS PROCEDURE 15.1 Every claim submitted to the Scheme in respect of the rendering of a relevant health service as contemplated in these Rules, must be accompanied by an account or statement as prescribed If an account, statement or claim is correct or where a corrected account, statement or claim is received, as the case may be, the Scheme must, in addition to the payment contemplated in Section 59(2) of the Act, dispatch to the member a statement containing at least the following particulars:- i. The name and the membership number of the member; ii. The name of the supplier of service; iii. The final date of service rendered by the supplier of service on the account or statement which is covered by the payment; iv. The total amount charged for the service concerned; and v. The amount of the benefit awarded for such service In order to qualify for benefits, any claim must, unless otherwise arranged, be signed and certified as correct and must be submitted to the Scheme not later than the last day of the fourth month following the month in which the service was rendered Where a member has paid an account, he shall, in support of his claim, submit a receipt Accounts for treatment of injuries or expenses recoverable from third parties, must be supported by a statement, setting out particulars of the circumstances in which the injury or accident was sustained Where the Scheme is of the opinion that a claim is incorrect or unacceptable for payment, the Scheme must notify the member and the health care provider, see regulation 6(2), accordingly within 30 days after receipt thereof. The Scheme must state the reasons why such claim is

22 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e 22 incorrect or unacceptable and afford such member and provider the opportunity to return such corrected claim to the Scheme within sixty days following the date from which it was returned for correction. 16. BENEFITS 16.1 Benefits extend through the member to his registered dependants. A member must, on admission, elect to participate in any one of the available options, detailed in Annexure B The Scheme will pay any benefit due to a member within 30 days of receipt of the claim pertaining to such benefit The benefit option offered in Annexure B covers in full the cost of the prescribed minimum benefits, in accordance with Annexure F The Scheme may exclude services from benefits as set out in Annexure C Benefits as per Annexure B may be increased in the case of Designated and Preferred Providers, subject to the approval of the Board The Scheme may recover from the Member any payment made to or on behalf of a Member whose contribution is in arrears, partly or in whole The Scheme may apply managed care protocols and clinical guidelines with due reference to evidence-based criteria to determine a Beneficiary s entitlement to benefits. 17. PAYMENT OF ACCOUNTS 17.1 Payment of accounts or reimbursement of claims is restricted to the net amount payable in respect of such benefit and maximum amount of the benefit to which the member is entitled in terms of the applicable benefit Any discount whether on an individual basis or bulk discount received in respect of a relevant health service shall be for the benefit of the member in determining the net amount payable for the service and appropriate deduction from the applicable benefit limit, or medical savings account, as the case may be The Scheme may, whether by agreement or not with any supplier or group of suppliers of a service, pay the benefit to which the member is entitled, directly to the supplier who rendered the service.

23 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e Where the Scheme has paid an account or portion of an account or any benefit to which a member is not entitled, whether payment is made to the member or to the supplier of service, the amount of any such overpayment is recoverable by the Scheme Notwithstanding the provisions of this Rule, the Scheme has the right to pay any benefit to the member concerned The Scheme may make Ex-Gratia payments to or for the benefit of a Beneficiary at its discretion in respect of any healthcare services which do not form part of a Beneficiary s entitlement in terms of his benefits and is subjected to the processes and limitations agreed to from time to time by its Board. An Ex-Gratia payment is a concession exercised at the discretion of the Board and not a right to which Members are entitled. 18. GOVERNANCE 18.1 The affairs of the Scheme must be managed according to these Rules by a Board of Trustees comprising 12 trustees. At least half of such trustees must be elected by members from amongst members (Member Representative Trustees) and the other half will be appointed by the Employer of the Group. An Employer Trustee need not be a Member to qualify to serve as an Employer Trustee The following persons are not eligible to serve as members of the Board: a person under the age of 21 years; an employee, director, officer, consultant, or contractor of the administrator of the Scheme or of the holding company, subsidiary, joint venture or associate of that administrator; (sec 57(3)) a broker; the auditor of the Scheme; the principal officer of the Scheme All trustees will be permitted to serve two consecutive terms of three years each. A person who has served two consecutive terms as a Trustee may be re-elected or reappointed to the Board for a further term after a period of five (5) years have passed since the date of expiry of his previous term on the Board. Nominations will be called for from the membership base during March of each year, closing at the end of March. Each candidate will have to be nominated by one member and will have to provide abbreviated Curriculum Vitae to introduce them to the members of the Scheme. During April proxy vote forms will be circulated to all members to vote. Voting will remain open for a period of a minimum of 30 days and will close 48 hours prior to the Annual

24 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e 24 General Meeting taking place. Any votes received after the deadline shall be considered as spoilt ballots. In the event that more than one candidate receives the same number of votes and there are insufficient seats on the Board available, the current Board shall be asked to cast their votes in a closed ballot in respect of such candidates. The final results will be reviewed and certified by Auditors and the results presented at the Annual General Meeting The Board may fill any casual vacancy, which occurs during its term of office. A vacant Member Representative Trustee position may be filled by a runner up person from the previous election and may be re-elected through the normal election process and ratified at the next annual general meeting. The Board may co-opt a knowledgeable person to assist it in its deliberations, provided that such person shall not have a vote Half of the members of the Board plus one present at a meeting is a quorum at meetings of the Board The Board must elect from its number the chairperson and vice-chairperson. In the absence of the chairperson and vice-chairperson, the Board members present must elect one of their numbers to preside Matters serving before the Board must be decided by a majority vote and in the event of an equality of votes, the chairperson has a casting vote in addition to his deliberative vote A member of the Board may resign at any time by giving written notice to the Board A member of the Board ceases to hold office if: he becomes mentally ill or incapable of managing his affairs; he is declared insolvent or has surrendered his estate for the benefit of his creditors; he is convicted, whether in the Republic or elsewhere, of theft, fraud, forgery or uttering of a forged document or perjury; he is removed by the court from any office of trust on account of misconduct; he is disqualified under any law from carrying on his profession; he ceases to be an appointee by a participating employer, or being a Board member elected by members of the Scheme, he ceases to be a member of the Scheme; or he absents himself from three consecutive meetings of the Board without the permission of the Chairman; he is removed from office by the Council in terms of Section 46 of the Act.18; he is removed in terms of Rule The Board must meet at least once every three months or as it deems fit.

25 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e The chairperson may convene a special meeting should the necessity arise. Any 3 members of the Board may request the chairperson to convene a special meeting of the Board, stating the matters to be discussed at such meeting Nominations to fill vacancies for Member Representative Trustees, signed by a proposer and seconder in good standing with the Scheme, must be signed by the candidate signifying his/her consent to stand for election and must be submitted to the Scheme together with a current curriculum vitae by 31 March of the year concerned and the election must be carried out by the members present at the annual general meeting of the Scheme Members of the Board are not entitled to any remuneration, honorarium, consulting fees or expenses incurred in the performance of their duties as trustees or any other fee in respect of services rendered in their capacity as members of the Board A member of the Board who acts in a manner which is seriously prejudicial to the interests of beneficiaries of the medical scheme may be removed by the Board, provided that: before the decision is taken to remove the member of the Board, the Board shall furnish that member with full details of the evidence which the Board has at its disposal regarding the conduct complained of, and allow such member a period of not less than 30 days in which to respond to the allegations; the resolution to remove that member is taken by at least two thirds of the members of the Board; the member shall have recourse to disputes procedures of the Scheme or complaints and appeal procedures provided for in the Act a Trustee removed in terms of the Rules shall not be eligible to be re-appointed or re-elected as a Trustee. 19. DUTIES OF BOARD OF TRUSTEES 19.1 The Board is responsible for the proper and sound management of the Scheme, at arm s length and in terms of these Rules The Board must act with due care, diligence, and skill and in good faith The Board must ensure that the interests of members are protected at all times including the provision of appropriate and adequate systems to accommodate timeous settlement of claims and the prompt response to inquiries, complaints and disputes.

26 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e Members of the Board must avoid conflicts of interests, and must declare any interest they may have in any particular matter serving before the Board The Board must apply sound business principles and ensure the financial soundness of the Scheme The Board must appoint a principal officer who is fit and proper to hold such office and any other staff members required for the proper execution of the business of the Scheme, and to determine the terms and conditions of service of any person employed by the Scheme The Chairperson must preside and preserve due and proper conduct at meetings The Board must cause to be kept such minutes, accounts, entries, registers and records as are essential for the proper functioning of the Scheme The Board must approve all disbursements The Board must cause to be kept in safe custody, in a safe or strong room at the registered office of the Scheme or with any financial institution approved by the Board, any mortgage bond, title deed or other security belonging to or held by the Scheme, except when in the temporary custody of another person for the purposes of the Scheme The Board must make such provision as it deems desirable, and with due regard to normal practice and recommended guidelines pertaining to retention of documents, for the safe custody of the books, records, documents and other effects of the Scheme The Board must ensure that adequate and appropriate information is communicated to the members regarding their rights, benefits, contributions and duties in terms of the Rules The Board must take all reasonable steps to ensure that contributions are paid timeously to the Scheme in accordance with the Act and the Rules The Board must take out and maintain an appropriate level of professional indemnity insurance and fidelity guarantee insurance The Board must obtain expert advice on legal, accounting and business matters as required, or on any other matter of which the members of the Board may lack sufficient expertise The Board must ensure that the Rules and the operation and administration of the Scheme comply with the provisions of the Act and all other applicable laws The Board must take all reasonable steps to protect the confidentiality of medical records concerning any member or dependant s state of health The Board shall disclose annually in writing to the Registrar, any payment or considerations made to them in that particular year by the Scheme.

27 N E T C A R E M E D I C A L S C H E M E R U L E S 2016 P a g e POWERS OF BOARD The Board has the power: 20.1 to cause the termination of the services of any employee of the Scheme; 20.2 to take all necessary steps and to sign and execute all necessary documents to ensure and secure the due fulfilment of the Scheme's obligations under such appointments; 20.3 to appoint a committee consisting of such Board members and other experts as it may deem appropriate; 20.4 to appoint a professional accredited administrator on such terms and conditions as it may determine, for the proper execution of the business of the Scheme. The terms and conditions of such appointment must be contained in a written contract which complies with the requirements of the Act and regulations; 20.5 to appoint, compensate and contract with any accredited broker for the introduction or admission of a member to the Scheme to appoint advisors or consultants to assist it in the performance of its duties; 20.7 to purchase movable and immovable property for the use of the Scheme or otherwise, and to sell it or any of it; 20.8 to let or hire movable or immovable property; 20.9 in respect of any moneys not immediately required to meet current charges upon the Scheme and subject to the provisions of the Act, and in the manner determined by the Board, invest or otherwise deal with such moneys upon security and to realise, re-invest or otherwise deal with such moneys and investments; with the prior approval of the Council, to borrow money for the Scheme from the Scheme's bankers against the security of the Scheme's assets for the purpose of bridging a temporary shortage; subject to the provisions of any law, to cause the Scheme, whether on its own or in association with any person, to establish or operate any pharmacy, hospital, clinic, maternity home, nursing home, infirmary, home for aged persons or any similar institution, in the interests of the members of the Scheme; to donate to any hospital, clinic, nursing home, maternity home, infirmary or home for aged persons in the interests of all or any of the beneficiaries; to grant repayable loans to members or to authorise ex gratia awards on behalf of members in order to assist such members to meet commitments in regard to the obtaining of a health care service;