Your Gap Cover and Health Insurance Provider INDIVIDUAL PRODUCT RANGE

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1 Your Gap Cover and Health Insurance Provider INDIVIDUAL PRODUCT RANGE

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3 Limpopo ENGAGE WITH US North West Johannesburg Mpumalanga Gauteng Free State KwaZulu-Natal Bloemfontein We are easy to locate and invite you to visit us for personal face-to-face service. Our head office is based in Johannesburg, with regional offices in Cape Town and Durban and satellite offices in Bloemfontein and Port Elizabeth. Northern Cape Eastern Cape Durban STRATUM BENEFITS (PTY) LTD REG NO.: 2003/018155/07 HEAD OFFICE 367 Surrey Avenue, Block C & D, Ferndale, Randburg, 2194 Suite 386, Private Bag X09, Weltevredenpark, 1715 t / f e info@stratumbenefits.co.za w CLIENT APPLICATION FORM SUBMISSIONS Submitting your Client Application Form is as easy as 1, 2, 3. e yourapplication@stratumbenefits.co.za CLIENT QUERIES AND POLICY ADMINISTRATION Contact one of our Client Support Specialists to enquire about your policy status or benefits, or to amend your policy profile. e yoursupport@stratumbenefits.co.za EMPLOYER GROUP SCHEME ADMINISTRATION Our team of Employer Group Scheme Specialists are available to assist with queries, updates or amendments to your employer group profile, employees details, tax invoices and billing statements. e yourinvoice@stratumbenefits.co.za Western Cape Cape Town Port Elizabeth BROKER PORTFOLIO ADMINISTRATION From enquiries and amendments pertaining to your brokerage s profile, to commission payments and queries, our team of Broker Portfolio Specialists are standing by to assist. e yourportfolio@stratumbenefits.co.za CLIENT CLAIM SUBMISSIONS AND ADMINISTRATION From claim submissions to enquiring about the progress on your claim, contact one of our Claims Specialists for assistance or feedback. STRATUM GAP COVER CLAIMS e yourclaim@stratumbenefits.co.za f STRATUM HEALTH INSURE CLAIMS e claims@unityhealth.co.za f REGIONAL OFFICES CAPE TOWN C/O Lubbe & Langeberg Roads, Unit 4, Frazzitta Business Park, Durbanville, 7550 t f DURBAN 2 Hopedene Grove, Main House, Morningside, Durban, 4001 t f SATELLITE OFFICE PORT ELIZABETH 10 Mendelssohn Avenue, Pari Park, Port Elizabeth, 6070 t f STRATUM HEALTH INSURE t f e info@stratumbenefits.co.za OPERATING HOURS Mon - Thurs 8:00-16:30 Fri 8:00-16:00 Sat 8:00-13:00 For Stratum Health Insure clients

4 GAP COVER 200 RANGE GAP COVER 500 RANGE EDGE COMPACT BASE 08 CO-EVOLUTION 10 GAP BENEFIT GAP BENEFIT GAP BENEFIT GAP BENEFIT CASUALTY BENEFIT CO-PAYMENT BENEFIT CASUALTY BENEFIT CO-PAYMENT BENEFIT ADDITIONAL BENEFIT - GAP POLICY PREMIUM WAIVER BENEFIT ONCOLOGY BENEFITS - ONCOLOGY BENEFIT - ONCOLOGY OPTIMISER BENEFIT - CANCER DIAGNOSIS BENEFIT SUB-LIMIT BENEFIT CASUALTY BENEFIT TRAUMA COUNSELLING BENEFIT CANCER DIAGNOSIS BENEFIT ADDITIONAL BENEFIT - ACCIDENTAL DEATH BENEFIT CASUALTY BENEFIT TRAUMA COUNSELLING BENEFIT CANCER DIAGNOSIS BENEFIT ADDITIONAL BENEFIT - ACCIDENTAL DEATH BENEFIT TRAUMA COUNSELLING BENEFIT ADDITIONAL BENEFIT - ACCIDENTAL DEATH BENEFIT

5 HEALTH INSURE RANGE GENERAL ELITE 12 ACCESS OPTIMISER 16 ESSENTIAL PRIMARY PLUS 23 CLAIMS EXAMPLES 15 GAP BENEFIT CO-PAYMENT BENEFIT ONCOLOGY BENEFITS - ONCOLOGY BENEFIT - ONCOLOGY OPTIMISER BENEFIT - CANCER DIAGNOSIS BENEFIT ACCESS OPTIMISER BENEFIT + ADD OUR GAP BENEFIT ADDITIONAL BENEFIT - ACCIDENTAL DEATH BENEFIT DAY-TO-DAY BENEFITS ONLY EMERGENCY AND ACCIDENTAL BENEFITS ONLY DAY-TO-DAY AND EMERGENCY & ACCIDENTAL BENEFITS ESSENTIAL WELLNESS BENEFITS GAP COVER PRODUCT RANGE OVERVIEW THE CLEAR PRINT SUB-LIMIT BENEFIT CASUALTY BENEFIT TRAUMA COUNSELLING BENEFIT REHABILITATION OPTIMISER BENEFIT PREVENTATIVE CARE BENEFIT ADDITIONAL BENEFITS - GAP POLICY PREMIUM AND MEDICAL SCHEME CONTRIBUTION WAIVER BENEFITS - ACCIDENTAL DEATH BENEFIT

6 GAP COVER FOR AN INDIVIDUAL WITH AN OVERALL POLICY LIMIT (OPL) OF R PER YEAR EDGE 200 ENTRY AGES MONTHLY PREMIUM * Single * Single 65+ * Single * Limited to one insured individual per policy WE COVER You, whether you are the main member or dependant on a medical scheme option. You, as the only individual insured on this option. R 100 R 180 R 300 Our EDGE 200 option has been innovatively designed to give you the best start when insuring yourself against unforeseen medical shortfalls. We cover you, as the only individual insured on this option, when your medical scheme does not pay your private healthcare fees in full, remove the anxiety of unforeseen expenses for a casualty event and cover your gap cover policy premium when life happens. 04 THIS POLICY IS A NON-MEDICAL SCHEME PRODUCT, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE

7 GAP BENEFIT Our GAP BENEFIT leaves you feeling assured that when an in- or out-of-hospital medical procedure is necessary and your service provider, such as your doctor or specialist, charges a rate more than what your medical scheme pays, the unexpected difference you are liable for won t leave you out of pocket. You are covered when your service providers charge a rate more than what your medical scheme pays for medical procedures performed in hospital, doctors and specialists private rooms, day clinics and other registered facilities, provided your service providers accounts are paid from your medical scheme hospital benefit, also known as a risk or major medical benefit, and not from your medical scheme savings account or day-to-day benefit. You are covered for Prescribed Minimum Benefit (PMB) medical procedures. CASUALTY BENEFIT Our CASUALTY BENEFIT offers rich benefits to ensure that you not only receive the very best medical care, but also not having to worry about an unforeseen out of pocket expense for a casualty event. You are covered at a registered medical facility in the event of an accident, when immediate treatment is required for physical injury resulting from an external force outside your body due to impact with someone or something. We will refund the cost of the casualty event to you when you become liable to pay out of your own pocket, or when your medical scheme pays the event from your medical scheme savings account. Our CASUALTY BENEFIT covers the cost of your casualty event up to R per year, for accounts related to the following: ADDITIONAL BENEFIT GAP POLICY PREMIUM WAIVER BENEFIT Our GAP POLICY PREMIUM WAIVER BENEFIT offers you the security of knowing that when you are faced with unexpected change resulting in financial difficulty, we have you covered. WHEN AND Our GAP POLICY PREMIUM WAIVER BENEFIT covers your Stratum Benefits policy premium for 12 months in the event of death, permanent disability or forced retrenchment of the Stratum Benefits policy premium payer. This benefit is not subject to the Overall Policy Limit (OPL). GAP COVER 200 EDGE 200 Our GAP BENEFIT provides an additional 200% cover, when you become liable for the difference between what your service providers charge, and what your medical scheme pays from your medical scheme hospital benefit for account shortfalls related to the following: Doctors and specialists Basic and specialised radiology Pathology Consumable items such as surgical gloves, bandages and gauze Medication provided as part of your casualty event at the registered medical facility Upfront casualty co-payments or facility fees Doctors and specialists Dentistry and related procedures limited to R per year Basic radiology Specialised radiology limited to MRI, CT and PET scans up to R per year Pathology Physiotherapy Consumable items such as surgical gloves, bandages and gauze Medication provided as part of your in- or out-of-hospital event Where a claim under our GAP BENEFIT is received for a condition, procedure, surgery, treatment or an investigation and any related accounts in respect of Adenoidectomy, Tonsillectomy, Myringotomy/Grommets, Cardiovascular procedures, Cataract removal, Dentistry, Hysterectomy (unless due to cancer diagnosis), Hernia repair, Joint replacement, MRI, CT and PET scans, Nasal and sinus surgery, Pregnancy and childbirth, Spinal procedures and Scopes within the first 10 months of cover, and is not deemed as pre-existing or accidental, 20% of the total claim amount will be payable. THIS POLICY IS A NON-MEDICAL SCHEME PRODUCT, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE 05

8 GAP COVER FOR INDIVIDUALS WITH AN OVERALL POLICY LIMIT (OPL) OF R PER PERSON PER YEAR COMPACT 200 ENTRY AGES MONTHLY PREMIUM 64 and younger Single R 180 Family R * Single or Family R 350 * Limited to two insured individuals per policy WE COVER INDIVIDUALS 64 AND YOUNGER We cover you and your spouse on one policy, even if you belong to different medical schemes or medical scheme options, including all dependants registered on your or your spouse s medical scheme option. INDIVIDUALS 65 AND OLDER We cover you and your spouse on one policy, even if you belong to different medical schemes or medical scheme options, or you and one other dependant registered on your medical scheme option. Where either one, or both individuals are 65 and older the 65+ premium will apply, limited to two insured individuals per policy. Our COMPACT 200 option has been conceptualised with medical scheme members in mind because when account shortfalls affect your financial wellbeing, we ll absorb the impact. Complete peace of mind is offered by our comprehensive benefits that fill the gaps in your medical scheme cover. We cover you when your medical scheme does not pay your private healthcare fees in full, refund upfront co-payment costs and lend a helping hand when you need oncology treatment GAP BENEFIT Our GAP BENEFIT leaves you feeling assured that when an in- or out-of-hospital medical procedure is necessary and your service provider, such as your doctor or specialist, charges a rate more than what your medical scheme pays, the unexpected difference you are liable for won t leave you out of pocket. CO-PAYMENT BENEFIT Our CO-PAYMENT BENEFIT provides you with the peace of mind that when your medical scheme requires you to pay upfront costs, we have you covered. You are covered when your service providers charge a rate more than what your medical scheme pays for medical procedures performed in hospital, doctors and specialists private rooms, day clinics and other registered facilities, provided your service providers accounts are paid from your medical scheme hospital benefit, also known as a risk or major medical benefit, and not from your medical scheme savings account or day-to-day benefit. You are covered for Prescribed Minimum Benefit (PMB) medical procedures. Our GAP BENEFIT provides an additional 200% cover, when you become liable for the difference between what your service providers charge, and what your medical scheme pays from your medical scheme hospital benefit for account shortfalls related to the following: You are covered when your medical scheme requires you to settle a fee, known as a co-payment, deductible or hospital admission fee, prior to undergoing certain in- and out-of-hospital medical procedures or specialised radiology scans. We will refund the co-payment, deductible or hospital admission fee which is either settled by you or deducted from your medical scheme savings account. Our CO-PAYMENT BENEFIT covers in- and out-of-hospital medical procedure related and specialised radiology scan co-payments, deductibles or hospital admission fees, represented as either a rand amount or a percentage and is limited to R per policy per year. Doctors and specialists Dentistry and related procedures limited to R per policy per year Basic radiology Specialised radiology limited to MRI, CT and PET scans up to R per policy per year Pathology Physiotherapy Consumable items such as surgical gloves, bandages and gauze Medication provided as part of your in- or out-of-hospital event 06 THIS POLICY IS A NON-MEDICAL SCHEME PRODUCT, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE

9 ONCOLOGY BENEFITS Our ONCOLOGY BENEFITS alleviate the financial pressure that is not conducive to an environment of healing, by offering you superior and unique benefits for your necessary oncology treatment. WHEN AND ONCOLOGY BENEFIT You are covered when your medical scheme only pays a portion towards your approved oncology treatment such as radiotherapy, chemotherapy, basic and specialised radiology, pathology, specialist consultations, registered oncology facility fees, biological or specialised medication etc. The difference you are liable for may be referred to as a co-payment by certain medical schemes, or may reflect as a rand amount where your service provider charges a rate more than what your medical scheme pays. Our ONCOLOGY BENEFIT covers you when your medical scheme only pays a portion towards your service providers accounts. ONCOLOGY OPTIMISER BENEFIT You are covered when your medical scheme provides you with an oncology benefit but applies a rand amount limit from which you can claim per year. Once this rand amount limit is reached, you will be liable to pay all treatment costs thereafter. Our ONCOLOGY OPTIMISER BENEFIT covers your oncology treatment costs when your medical scheme no longer does and is limited to R per person per year. CANCER DIAGNOSIS BENEFIT Our CANCER DIAGNOSIS BENEFIT provides a once-off payment of R when you are diagnosed with cancer for the first time and the diagnosis aligns to specific qualifying criteria. This benefit is not subject to the Overall Policy Limit (OPL). SUB-LIMIT BENEFIT Our SUB-LIMIT BENEFIT affords you the opportunity to ensure that your health and recovery remain a priority, when your medical scheme applies a rand amount limit to your internal prostheses benefit, leaving you liable to pay a portion of the cost. You are covered when your medical scheme provides you with a rand amount limit, known as a sub-limit or annual limit, from which you can claim for an internal prosthesis but the device costs more than the amount your medical scheme pays. Our SUB-LIMIT BENEFIT provides cover when you become liable to settle a portion of your internal prosthesis provider s account, up to R per event with a maximum of R per person per year. CASUALTY BENEFIT Our CASUALTY BENEFIT offers rich benefits to ensure that you not only receive the very best medical care, but also not having to worry about an unforeseen out of pocket expense for a casualty event. You are covered at a registered medical facility in the event of an accident, when immediate treatment is required for physical injury resulting from an external force outside your body due to impact with someone or something. We will refund the cost of the casualty event to you when you become liable to pay out of your own pocket, or when your medical scheme pays the event from your medical scheme savings account. Our CASUALTY BENEFIT covers the cost of your casualty event up to R per policy per year, for accounts related to the following: Doctors and specialists Basic and specialised radiology Pathology Consumable items such as surgical gloves, bandages and gauze Medication provided as part of your casualty event at the registered medical facility Upfront casualty co-payments or facility fees TRAUMA COUNSELLING BENEFIT Our TRAUMA COUNSELLING BENEFIT ensures you receive the support you need, when circumstances outside of your control alter the course of your life. You are covered when you have witnessed, or are directly affected by an act of physical violence or an accident resulting in serious bodily injury or death. You are also covered when you are diagnosed with a dread disease, or are affected by a loved one s diagnosis of a dread disease or death. We will refund the cost of the registered counsellor s, clinical psychologist s or psychiatrist s consultation fee when you become liable to pay out of your own pocket, or when your medical scheme pays the fees from your medical scheme savings account. Our TRAUMA COUNSELLING BENEFIT covers your consultation fees up to R per policy per year. ADDITIONAL BENEFIT ACCIDENTAL DEATH BENEFIT Our ACCIDENTAL DEATH BENEFIT offers you and your loved ones the security of knowing that when you are faced with unexpected change resulting in financial difficulty, we have you covered. WHEN AND Our ACCIDENTAL DEATH BENEFIT provides a payment of R in the event of the accidental death of the principal insured or spouse and R for the accidental death of a dependant. This benefit is not subject to the Overall Policy Limit (OPL). Where a claim under our GAP BENEFIT, CO-PAYMENT BENEFIT or SUB-LIMIT BENEFIT is received for a condition, procedure, surgery, treatment or an investigation and any related accounts in respect of Adenoidectomy, Tonsillectomy, Myringotomy/Grommets, Cardiovascular procedures, Cataract removal, Dentistry, Hysterectomy (unless due to cancer diagnosis), Hernia repair, Joint replacement, MRI, CT and PET scans, Nasal and sinus surgery, Pregnancy and childbirth, Spinal procedures and Scopes within the first 10 months of cover, and is not deemed as pre-existing or accidental, 20% of the total claim amount will be payable. GAP COVER 200 COMPACT 200 THIS POLICY IS A NON-MEDICAL SCHEME PRODUCT, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE 07

10 GAP COVER FOR INDIVIDUALS WITH AN OVERALL POLICY LIMIT (OPL) OF R PER PERSON PER YEAR BASE ENTRY AGES 64 and younger 65+ * WE COVER MONTHLY PREMIUM Single Single or R 180 Family Family R 205 R 350 *Limited to two insured individuals per policy INDIVIDUALS 64 AND YOUNGER We cover you and your spouse on one policy, even if you belong to different medical schemes or medical scheme options, including all dependants registered on your or your spouse s medical scheme option. INDIVIDUALS 65 AND OLDER We cover you and your spouse on one policy, even if you belong to different medical schemes or medical scheme options, or you and one other dependant registered on your medical scheme option. Where either one, or both individuals are 65 and older the 65+ premium will apply, limited to two insured individuals per policy. Our BASE option provides real cover with real benefits when your medical scheme does not pay your private healthcare fees in full, when the unforeseen expense of a casualty event causes anxiety and lends emotional and financial support when circumstances outside of your control alter the course of your life. GAP BENEFIT Our GAP BENEFIT leaves you feeling assured that when an in- or out-of-hospital medical procedure is necessary and your service provider, such as your doctor or specialist, charges a rate more than what your medical scheme pays, the unexpected difference you are liable for won t leave you out of pocket. You are covered when your service providers charge a rate more than what your medical scheme pays for medical procedures performed in hospital, doctors and specialists private rooms, day clinics and other registered facilities, provided your service providers accounts are paid from your medical scheme hospital benefit, also known as a risk or major medical benefit, and not from your medical scheme savings account or day-to-day benefit. You are covered for Prescribed Minimum Benefit (PMB) medical procedures. Our GAP BENEFIT provides an additional 500% cover, when you become liable for the difference between what your service providers charge, and what your medical scheme pays from your medical scheme hospital benefit for account shortfalls related to the following: Doctors and specialists Dentistry and related procedures limited to R per policy per year Basic radiology Specialised radiology limited to MRI, CT and PET scans up to R per policy per year Pathology Physiotherapy Consumable items such as surgical gloves, bandages and gauze Medication provided as part of your in- or out-of-hospital event 08 THIS POLICY IS A NON-MEDICAL SCHEME PRODUCT, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE

11 CASUALTY BENEFIT TRAUMA COUNSELLING BENEFIT CANCER DIAGNOSIS BENEFIT GAP COVER 500 BASE Our CASUALTY BENEFIT offers you rich benefits to ensure that you not only receive the very best medical care, but also not having to worry about an unforeseen out of pocket expense for a casualty event. You are covered at a registered medical facility in the event of an accident, when immediate treatment is required for physical injury resulting from an external force outside your body due to impact with someone or something. We will refund the cost of the casualty event to you when you become liable to pay out of your own pocket, or when your medical scheme pays the event from your medical scheme savings account. Our CASUALTY BENEFIT covers the cost of your casualty event up to R per policy per year, for accounts related to the following: Our TRAUMA COUNSELLING BENEFIT ensures you receive the support you need, when circumstances outside of your control alter the course of your life. You are covered when you have witnessed, or are directly affected by an act of physical violence or an accident resulting in serious bodily injury or death. You are also covered when you are diagnosed with a dread disease, or are affected by a loved one s diagnosis of a dread disease or death. We will refund the cost of the registered counsellor s, clinical psychologist s or psychiatrist s consultation fee when you become liable to pay out of your own pocket, or when your medical scheme pays the fees from your medical scheme savings account. Our CANCER DIAGNOSIS BENEFIT lends a helping hand by offering a humble gesture that assists you on the road to recovery. WHEN AND Our CANCER DIAGNOSIS BENEFIT provides a once-off payment of R when you are diagnosed with cancer for the first time and the diagnosis aligns to specific qualifying criteria. This benefit is not subject to the Overall Policy Limit (OPL). ADDITIONAL BENEFIT ACCIDENTAL DEATH BENEFIT Our ACCIDENTAL DEATH BENEFIT offers you and your spouse the security of knowing that when you are faced with unexpected change due to the loss of a loved one, we have you covered. Doctor or specialist consultations Basic and specialised radiology Pathology Consumable items such as surgical gloves, bandages and gauze Medication provided as part of your casualty event at the registered medical facility Upfront casualty co-payments or facility fees Our TRAUMA COUNSELLING BENEFIT covers your consultation fees up to R per policy per year. WHEN AND Our ACCIDENTAL DEATH BENEFIT provides a payment of R in the event of the accidental death of the principal insured or spouse. This benefit is not subject to the Overall Policy Limit (OPL). Where a claim under our GAP BENEFIT is received for a condition, procedure, surgery, treatment or an investigation and any related accounts in respect of Adenoidectomy, Tonsillectomy, Myringotomy/Grommets, Cardiovascular procedures, Cataract removal, Dentistry, Hysterectomy (unless due to cancer diagnosis), Hernia repair, Joint replacement, MRI, CT and PET scans, Nasal and sinus surgery, Pregnancy and childbirth, Spinal procedures and Scopes within the first 10 months of cover, and is not deemed as pre-existing or accidental, 20% of the total claim amount will be payable. THIS POLICY IS A NON-MEDICAL SCHEME PRODUCT, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE 09

12 GAP COVER FOR INDIVIDUALS WITH AN OVERALL POLICY LIMIT (OPL) OF R PER PERSON PER YEAR CO-EVOLUTION ENTRY AGES 64 and younger 65+ * WE COVER MONTHLY PREMIUM Single Single or R 200 Family Family R 250 R 400 *Limited to two insured individuals per policy INDIVIDUALS 64 AND YOUNGER We cover you and your spouse on one policy, even if you belong to different medical schemes or medical scheme options, including all dependants registered on your or your spouse s medical scheme option. INDIVIDUALS 65 AND OLDER We cover you and your spouse on one policy, even if you belong to different medical schemes or medical scheme options, or you and one other dependant registered on your medical scheme option. Where either one, or both individuals are 65 and older the 65+ premium will apply, limited to two insured individuals per policy. Our CO-EVOLUTION option has been expertly combined to provide just the right benefits when unforeseen medical expenses occur. From covering the gap that exists when your medical scheme does not pay your private healthcare fees in full, to benefits for co-payments, casualty events, trauma counselling, cancer diagnosis and accidental death, you can rest assured that we have you covered. 10 THIS POLICY IS A NON-MEDICAL SCHEME PRODUCT, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE

13 GAP BENEFIT Our GAP BENEFIT leaves you feeling assured that when an in- or out-of-hospital medical procedure is necessary and your service provider, such as your doctor or specialist, charges a rate more than what your medical scheme pays, the unexpected difference you are liable for won t leave you out of pocket. You are covered when your service providers charge a rate more than what your medical scheme pays for medical procedures performed in hospital, doctors and specialists private rooms, day clinics and other registered facilities, provided your service providers accounts are paid from your medical scheme hospital benefit, also known as a risk or major medical benefit, and not from your medical scheme savings account or day-to-day benefit. You are covered for Prescribed Minimum Benefit (PMB) medical procedures. Our GAP BENEFIT provides an additional 500% cover, when you become liable for the difference between what your service providers charge, and what your medical scheme pays from your medical scheme hospital benefit for account shortfalls related to the following: Doctors and specialists Dentistry and related procedures limited to R per policy per year Basic radiology Specialised radiology limited to MRI, CT and PET scans up to R per policy per year Pathology Physiotherapy Consumable items such as surgical gloves, bandages and gauze Medication provided as part of your in- or out-of-hospital event Where a claim under our GAP BENEFIT or CO-PAYMENT BENEFIT is received for a condition, procedure, surgery, treatment or an investigation and any related accounts in respect of Adenoidectomy, Tonsillectomy, Myringotomy/Grommets, Cardiovascular procedures, Cataract removal, Dentistry, Hysterectomy (unless due to cancer diagnosis), Hernia repair, Joint replacement, MRI, CT and PET scans, Nasal and sinus surgery, Pregnancy and childbirth, Spinal procedures and Scopes within the first 10 months of cover, and is not deemed as pre-existing or accidental, 20% of the total claim amount will be payable. CO-PAYMENT BENEFIT Our CO-PAYMENT BENEFIT provides you with the peace of mind that when your medical scheme requires you to pay upfront costs, we have you covered. You are covered when your medical scheme requires you to settle a fee, known as a co-payment, deductible or hospital admission fee, prior to undergoing certain in- and out-of-hospital medical procedures or specialised radiology scans. We will refund the co-payment, deductible or hospital admission fee which is either settled by you or deducted from your medical scheme savings account. Our CO-PAYMENT BENEFIT covers in- and out-of-hospital medical procedure related and specialised radiology scan co-payments, deductibles or hospital admission fees, represented as either a rand amount or a percentage and is limited to R per policy per year. CASUALTY BENEFIT Our CASUALTY BENEFIT offers you rich benefits to ensure that you not only receive the very best medical care, but also not having to worry about an unforeseen out of pocket expense for a casualty event. You are covered at a registered medical facility in the event of an accident, when immediate treatment is required for physical injury resulting from an external force outside your body due to impact with someone or something. We will refund the cost of the casualty event to you when you become liable to pay out of your own pocket, or when your medical scheme pays the event from your medical scheme savings account. Our CASUALTY BENEFIT covers the cost of your casualty event up to R per policy per year, for accounts related to the following: Doctor or specialist consultations Basic and specialised radiology Pathology Consumable items such as surgical gloves, bandages and gauze Medication provided as part of your casualty event at the registered medical facility Upfront casualty co-payments or facility fees TRAUMA COUNSELLING BENEFIT Our TRAUMA COUNSELLING BENEFIT ensures you receive the support you need and deserve, when circumstances outside of your control alter the course of your life. You are covered when you have witnessed, or are directly affected by an act of physical violence or an accident resulting in serious bodily injury or death. You are also covered when you are diagnosed with a dread disease, or are affected by a loved one s diagnosis of a dread disease or death. We will refund the cost of the registered counsellor s, clinical psychologist s or psychiatrist s consultation fee when you become liable to pay out of your own pocket, or when your medical scheme pays the fees from your medical scheme savings account. Our TRAUMA COUNSELLING BENEFIT covers your consultation fees up to R per policy per year. CANCER DIAGNOSIS BENEFIT Our CANCER DIAGNOSIS BENEFIT lends a helping hand by offering a humble gesture that assists you on the road to recovery. WHEN AND Our CANCER DIAGNOSIS BENEFIT provides a once-off payment of R when you are diagnosed with cancer for the first time and the diagnosis aligns to specific qualifying criteria. This benefit is not subject to the Overall Policy Limit (OPL). ADDITIONAL BENEFIT ACCIDENTAL DEATH BENEFIT Our ACCIDENTAL DEATH BENEFIT offers you and your spouse the security of knowing that when you are faced with unexpected change due to the loss of a loved one, we have you covered. WHEN AND Our ACCIDENTAL DEATH BENEFIT provides a payment of R in the event of the accidental death of the principal insured or spouse. This benefit is not subject to the Overall Policy Limit (OPL). GAP COVER 500 CO-EVOLUTION THIS POLICY IS A NON-MEDICAL SCHEME PRODUCT, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE 11

14 GAP COVER FOR INDIVIDUALS WITH AN OVERALL POLICY LIMIT (OPL) OF R PER PERSON PER YEAR ELITE ENTRY AGES 64 and younger 65+ * WE COVER MONTHLY PREMIUM Single Single or R 295 Family Family R 355 R 575 *Limited to two insured individuals per policy INDIVIDUALS 64 AND YOUNGER We cover you and your spouse on one policy, even if you belong to different medical schemes or medical scheme options, including all dependants registered on your or your spouse s medical scheme option. INDIVIDUALS 65 AND OLDER We cover you and your spouse on one policy, even if you belong to different medical schemes or medical scheme options, or you and one other dependant registered on your medical scheme option. Where either one, or both individuals are 65 and older the 65+ premium will apply, limited to two insured individuals per policy. Our ELITE option has been thoughtfully created with a clear vision to provide elite benefits that offer best-in-class cover, to ensure complete peace of mind knowing we have you covered. This option is perfectly suited for individuals who don t compromise on cover. We don t. GAP BENEFIT Our GAP BENEFIT leaves you feeling assured that when an in- or out-of-hospital medical procedure is necessary and your service provider, such as your doctor or specialist, charges a rate more than what your medical scheme pays, the unexpected difference you are liable for won t leave you out of pocket. You are covered when your service providers charge a rate more than what your medical scheme pays for medical procedures performed in hospital, doctors and specialists private rooms, day clinics and other registered facilities, provided your service providers accounts are paid from your medical scheme hospital benefit, also known as a risk or major medical benefit, and not from your medical scheme savings account or day-to-day benefit. You are covered for Prescribed Minimum Benefit (PMB) medical procedures. Our GAP BENEFIT provides an additional 500% cover, when you become liable for the difference between what your service providers charge, and what your medical scheme pays from your medical scheme hospital benefit for account shortfalls related to the following: Doctors and specialists Dentistry and related procedures limited to R per policy per year Basic radiology Specialised radiology limited to MRI, CT and PET scans up to R per policy per year Pathology Physiotherapy Consumable items such as surgical gloves, bandages and gauze Medication provided as part of your in- or out-of-hospital event 12 THIS POLICY IS A NON-MEDICAL SCHEME PRODUCT, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE

15 CO-PAYMENT BENEFIT ONCOLOGY BENEFITS SUB-LIMIT BENEFIT GAP COVER 500 ELITE Our CO-PAYMENT BENEFIT provides you with the peace of mind that when your medical scheme requires you to pay upfront costs, we have you covered. You are covered when your medical scheme requires you to settle a fee, known as a co-payment, deductible or hospital admission fee, prior to undergoing certain in- and out-of-hospital medical procedures or specialised radiology scans. We will refund the co-payment, deductible or hospital admission fee, which is either settled by you or deducted from your medical scheme savings account. Our CO-PAYMENT BENEFIT covers in- and out-of-hospital medical procedure related and specialised radiology scan co-payments, deductibles or hospital admission fees, represented as either a rand amount or a percentage. You are also covered for 1 co-payment up to an amount of R per policy per year, for the voluntary use of a hospital or day clinic outside your medical scheme s designated network. Where a claim under our GAP BENEFIT, CO-PAYMENT BENEFIT or SUB-LIMIT BENEFIT is received for a condition, procedure, surgery, treatment or an investigation and any related accounts in respect of Adenoidectomy, Tonsillectomy, Myringotomy/Grommets, Cardiovascular procedures, Cataract removal, Dentistry, Hysterectomy (unless due to cancer diagnosis), Hernia repair, Joint replacement, MRI, CT and PET scans, Nasal and sinus surgery, Pregnancy and childbirth, Spinal procedures and Scopes within the first 10 months of cover, and is not deemed as pre-existing or accidental, 20% of the total claim amount will be payable, where applicable. Our ONCOLOGY BENEFITS alleviate the financial pressure that is not conducive to an environment of healing, by offering you superior and unique benefits for your necessary oncology treatment. WHEN AND ONCOLOGY BENEFIT You are covered when your medical scheme only pays a portion towards your approved oncology treatment such as radiotherapy, chemotherapy, basic and specialised radiology, pathology, specialist consultations, registered oncology facility fees, biological or specialised medication etc. The difference you are liable for may be referred to as a co-payment by certain medical schemes, or may reflect as a rand amount where your service provider charges a rate more than what your medical scheme pays. Our ONCOLOGY BENEFIT covers you when your medical scheme only pays a portion towards your service providers accounts. ONCOLOGY OPTIMISER BENEFIT You are covered when your medical scheme provides you with an oncology benefit but applies a rand amount limit from which you can claim per year. Once this rand amount limit is reached, you will be liable to pay all treatment costs thereafter. Our ONCOLOGY OPTIMISER BENEFIT covers your oncology treatment costs when your medical scheme no longer does. CANCER DIAGNOSIS BENEFIT Our CANCER DIAGNOSIS BENEFIT provides a once-off payment of R when you are diagnosed with cancer for the first time and the diagnosis aligns to specific qualifying criteria. This benefit is not subject to the Overall Policy Limit (OPL). Our SUB-LIMIT BENEFIT affords you the opportunity to ensure that your health and recovery remain a priority, when your medical scheme applies a rand amount limit to specific service providers accounts, leaving you liable to pay a portion of, or the full amount of the account. You are covered when your medical scheme provides you with a rand amount limit, known as a sub-limit or annual limit, from which you can claim for internal prostheses, non-pmb day procedures, renal dialysis and MRI & CT scans but the device, procedure, treatment or scan costs more than the amount your medical scheme pays. You are also covered when your medical scheme provides you with a MRI & CT scan benefit but applies a rand amount limit, known as a sub-limit or annual limit, from which you can claim every year. Once this rand amount limit is reached, you will be liable to pay all costs thereafter. Our SUB-LIMIT BENEFIT provides cover when you become liable to settle a portion of your internal prosthesis provider s account, or the service providers accounts relating to your non-pmb day procedure or renal dialysis treatment, up to R per event with a maximum of R per person per year. You will also be covered for a total number of 2 MRI or CT scans up to an amount of R per scan per policy per year, when you become liable to settle a portion of, or the full amount of your service provider s account. THIS POLICY IS A NON-MEDICAL SCHEME PRODUCT, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE 13

16 GAP COVER 500 ELITE CONTINUED CASUALTY BENEFIT Our CASUALTY BENEFIT offers you rich benefits to ensure that you not only receive the very best medical care, but also not having to worry about an unforeseen out of pocket expense for a casualty event. You are covered at a registered medical facility in the event of an accident, when immediate treatment is required for physical injury resulting from an external force outside your body due to impact with someone or something. We will refund the cost of the casualty event to you when you become liable to pay out of your own pocket, or when your medical scheme pays the event from your medical scheme savings account. Our CASUALTY BENEFIT covers the cost of your casualty event up to R per policy per year, for accounts related to the following: Doctor or specialist consultations Basic and specialised radiology Pathology Consumable items such as surgical gloves, bandages and gauze Medication provided as part of your casualty event at the registered medical facility Upfront casualty co-payments or facility fees TRAUMA COUNSELLING BENEFIT Our TRAUMA COUNSELLING BENEFIT ensures you receive the support you need and deserve, when circumstances outside of your control alter the course of your life. You are covered when you have witnessed, or are directly affected by an act of physical violence or an accident resulting in serious bodily injury or death. You are also covered when you are diagnosed with a dread disease, or are affected by a loved one s diagnosis of a dread disease or death. We will refund the cost of the registered counsellor s, clinical psychologist s or psychiatrist s consultation fee when you become liable to pay out of your own pocket, or when your medical scheme pays the fees from your medical scheme savings account. Our TRAUMA COUNSELLING BENEFIT covers your consultation fees up to R per policy per year. REHABILITATION OPTIMISER BENEFIT Our REHABILITATION OPTIMISER BENEFIT helps to get your life back on course, when you need physical rehabilitative care and access to skilled therapists in the event of an unforeseen accident. PREVENTATIVE CARE BENEFIT Our PREVENTATIVE CARE BENEFIT has been caringly put together to provide you the opportunity to undergo specific preventative screening tests when you are concerned about your health and wellbeing. You are covered when you undergo a Pap smear, prostate screening (PSA test) or a full blood count (FBC test) to help diagnose certain cancers. We will refund the cost of your service provider s consultation fee and the cost of your test when you become liable to pay out of your own pocket, or when your medical scheme pays the cost from your medical scheme savings account. Our PREVENTATIVE CARE BENEFIT covers your consultation fees or the cost of the tests up to an amount of R 500 per policy per year. ADDITIONAL BENEFITS Our ADDITIONAL BENEFITS offer you and your loved ones the security of knowing that when you are faced with unexpected change resulting in financial difficulty, your cover will remain unchanged because we have you covered. WHEN AND You are covered when your medical scheme provides you with a rehabilitation benefit for accidental events, but applies a rand amount limit or a limit to the number of days you may be admitted, from which you can claim per year. Once these limits are reached, you will be liable to pay all treatment costs thereafter. Our REHABILITATION OPTIMISER BENEFIT covers your rehabilitation treatment provided by on-site therapists as well as your stay at a registered sub-acute or step-down facility, when your medical scheme no longer does and is limited to R per person per year. Our GAP POLICY PREMIUM WAIVER BENEFIT covers your Stratum Benefits policy premium for 12 months in the event of death, permanent disability or forced retrenchment of the Stratum Benefits policy premium payer. Our MEDICAL SCHEME CONTRIBUTION WAIVER BENEFIT covers your medical scheme contribution for 6 months to a maximum of R per month, in the event of death or permanent disability of the medical scheme contribution payer. Our ACCIDENTAL DEATH BENEFIT provides a payment of R in the event of the accidental death of the principal insured or spouse and R for the accidental death of a dependant. These benefits are not subject to the Overall Policy Limit (OPL). 14 THIS POLICY IS A NON-MEDICAL SCHEME PRODUCT, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE

17 CLAIMS EXAMPLES Our GAP BENEFIT provides shortfall cover, when you become liable for the difference between what your service providers charge and what your medical scheme pays for account shortfalls related to doctors and specialists. Below are two examples of how our 500% GAP BENEFIT ensures your medical shortfalls are covered. CLAIM FOR CHILDBIRTH UNDER OUR GAP BENEFIT SERVICE PROVIDERS SERVICE PROVIDERS CHARGED YOUR MEDICAL SCHEME PAID GAP BENEFIT WILL COVER YOU ARE LIABLE FOR Gynaecologist R R R R 0 Anaesthetist R R R R 0 Total R R R R 0 CLAIM FOR COLONOSCOPY UNDER OUR GAP BENEFIT SERVICE PROVIDERS SERVICE PROVIDERS CHARGED YOUR MEDICAL SCHEME PAID GAP BENEFIT WILL COVER YOU ARE LIABLE FOR Specialist R R R R 0 Anaesthetist R R R R 0 Total R R R R 0 GAP COVER CLAIMS EXAMPLES Our CASUALTY BENEFIT provides a rand amount limit from which you can claim for costs at a registered medical facility for accidental events, when immediate treatment is required for physical injury. When your medical scheme does not provide you with cover or pays a casualty event from your available medical scheme savings account, you can rest assured that we have you covered. CLAIM FOR A FRACTURED ARM UNDER OUR CASUALTY BENEFIT SERVICE PROVIDERS SERVICE PROVIDERS CHARGED YOUR MEDICAL SCHEME PAID CASUALTY BENEFIT WILL COVER YOU ARE LIABLE FOR Treating Doctor R R 0 R R 0 Facility Fee R R 0 R R 0 Total R R 0 R R 0 Our ACCESS OPTIMISER BENEFIT provides you with the necessary cover when a medical procedure is required that is not claimable from your medical scheme, because the procedure is listed as a specific exclusion. We cover your hospital and service providers accounts up to a rand amount limit for specific medical procedures. The claims example below indicates the amount covered for a specific medical procedure which was excluded by the medical scheme. CLAIM FOR A KNEE ARTHROSCOPY UNDER OUR ACCESS OPTIMISER BENEFIT SERVICE PROVIDERS SERVICE PROVIDERS CHARGED YOUR MEDICAL SCHEME PAID ACCESS OPT. BENEFIT WILL COVER YOU ARE LIABLE FOR Specialist R R 0 R R 0 Anaesthetist R R 0 R R 0 Hospital R R 0 R R 0 Total R R 0 R R 0 T S & C S APPLY E&OE 15

18 GAP COVER FOR INDIVIDUALS WITH AN OVERALL POLICY LIMIT (OPL) OF R PER POLICY PER YEAR OR WHEN ADDING OUR GAP BENEFIT INCREASES TO R PER POLICY PER YEAR ACCESS OPTIMISER ENTRY AGES MONTHLY PREMIUM 64 and younger Single or Family R 235 Add our Gap Benefit R * Single or Family R 285 Add our Gap Benefit R 115 *Limited to two insured individuals per policy WE COVER INDIVIDUALS 64 AND YOUNGER We cover you and your spouse on one policy, even if you belong to different medical schemes or medical scheme options, including all dependants registered on your or your spouse s medical scheme option. INDIVIDUALS 65 AND OLDER We cover you and your spouse on one policy, even if you belong to different medical schemes or medical scheme options, or you and one other dependant registered on your medical scheme option. Where either one, or both individuals are 65 and older the 65+ premium will apply, limited to two insured individuals per policy. Our ACCESS OPTIMISER option has been skilfully designed to provide you with the necessary cover for a medical procedure that is not claimable from your medical scheme, because the procedure is listed as a specific exclusion. 16 THIS POLICY IS A NON-MEDICAL SCHEME PRODUCT, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE

19 ACCESS OPTIMISER BENEFIT Our ACCESS OPTIMISER BENEFIT leaves you feeling comforted and confident knowing that when your medical scheme does not cover specific medical procedures that are excluded but necessary for your wellbeing, your gap cover provider will. You are covered when your medical scheme excludes a medical procedure that forms part of a specific list of exclusions, over and above the general exclusions applicable to your medical scheme option, leaving you liable to pay all hospital and related service providers accounts in full. Our ACCESS OPTIMISER BENEFIT provides cover for your hospital and service providers accounts up to the rand amount limit for the below listed medical procedures: MEDICAL PROCEDURE NOT COVERED BY YOUR MEDICAL SCHEME ACCESS OPTIMISER BENEFIT WILL COVER Arthroscopic surgery R Back or neck surgery R Bunion surgery R Cochlear implant, auditory brain implant and internal nerve stimulator surgery including the device and processor Dental procedures for impacted teeth for child dependants under 18 years of age Dental procedures for reconstructive plastic surgery due to an accident R R R Functional nasal surgery R Joint replacement surgery R Knee or shoulder surgery R Oesophageal reflux and hiatus hernia surgery R Varicose veins surgery R IMPORTANT TO KNOW Our ACCESS OPTIMISER BENEFIT grants you the freedom of choice when your doctor informs you that you require a medically necessary procedure but your medical scheme excludes the procedure because it is listed as a specific exclusion. We do not decide which service providers you may use but allow you to inform us of whom you trust. The rand amount limits our ACCESS OPTIMISER BENEFIT provides for the medical procedure you require, will be used to cover all service providers costs. You will be liable for the difference where your chosen service providers charge a rate that exceeds the rand amount limit we provide. You will be required to provide us with a quotation from each service provider, whom we will contact on your behalf and provide a guarantee of payment where applicable. Payment will be made directly to the service providers once your claim has been approved. ADD OUR GAP BENEFIT Our ACCESS OPTIMISER BENEFIT covers medically necessary procedures that your medical scheme won t. When our GAP BENEFIT is added at an additional monthly premium as per the premium breakdown, the shortfall that exists between what your medical scheme pays and the fee charged for private healthcare for medical procedures that do not form part of your medical scheme s list of specific exclusions, will be covered. Our GAP BENEFIT leaves you feeling assured that when an in- or out-of-hospital medical procedure is necessary and your service provider, such as your doctor or specialist, charges a rate more than what your medical scheme pays, the unexpected difference you are liable for won t leave you out of pocket. You are covered when your service providers charge a rate more than what your medical scheme pays for medical procedures performed in hospital, doctors and specialists private rooms, day clinics and other registered facilities, provided your service providers accounts are paid from your medical scheme hospital benefit, also known as a risk or major medical benefit, and not from your medical scheme savings account or day-to-day benefit. You are covered for Prescribed Minimum Benefit (PMB) medical procedures. Our GAP BENEFIT provides an additional 500% cover, when you become liable for the difference between what your service providers charge, and what your medical scheme pays from your medical scheme hospital benefit for account shortfalls related to the following: Doctors and specialists Dentistry and related procedures limited to R per policy per year Basic radiology Specialised radiology limited to MRI, CT and PET scans up to R per policy per year Pathology Physiotherapy Consumable items such as surgical gloves, bandages and gauze Medication provided as part of your in- or out-of-hospital event Where a claim under our GAP BENEFIT is received for a condition, procedure, surgery, treatment or an investigation and any related accounts in respect of Adenoidectomy, Tonsillectomy, Myringotomy/ Grommets, Cardiovascular procedures, Cataract removal, Dentistry, Hysterectomy (unless due to cancer diagnosis), Hernia repair, Joint replacement, MRI, CT and PET scans, Nasal and sinus surgery, Pregnancy and childbirth, Spinal procedures and Scopes within the first 10 months of cover, and is not deemed as pre-existing or accidental, 20% of the total claim amount will be payable. ADDITIONAL BENEFIT ACCIDENTAL DEATH BENEFIT Our ACCIDENTAL DEATH BENEFIT offers you and your spouse the security of knowing that when you are faced with unexpected change due to the loss of a loved one, we have you covered. WHEN AND Our ACCIDENTAL DEATH BENEFIT provides a payment of R in the event of the accidental death of the principal insured or spouse. This benefit is not subject to the Overall Policy Limit (OPL). GAP COVER 500 ACCESS OPTIMISER Where a claim under our ACCESS OPTIMISER BENEFIT is received for a condition, procedure, surgery, treatment or an investigation and any related accounts in respect of Arthroscopic surgery, Back or neck surgery, Bunion surgery, Cochlear implant, auditory brain implant and internal nerve stimulator surgery including the device and processor, Dental procedures for impacted teeth for child dependants under 18 years of age, Dental procedures for reconstructive plastic surgery due to an accident, Functional nasal surgery, Joint replacement surgery, Knee or shoulder surgery, Oesophageal reflux and hiatus hernia surgery, Varicose veins surgery within the first 10 months of cover, and is not deemed as pre-existing or accidental, 20% of the total claim amount will be payable. THIS POLICY IS A NON-MEDICAL SCHEME PRODUCT, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE 17

20 GAP COVER PRODUCT RANGE OVERVIEW EDGE 200 COMPACT 200 BASE CO-EVOLUTION ELITE ACCESS OPTIMISER 2018 PRODUCT OVERVIEW Our EDGE 200 option has been innovatively designed to give you the best start when insuring yourself against unforeseen medical shortfalls. We cover you, as the only individual insured on this option, when your medical scheme does not pay your private healthcare fees in full, remove the anxiety of unforeseen expenses for a casualty event and cover your gap cover policy premium when life happens. GAP BENEFIT CASUALTY BENEFIT ADDITIONAL BENEFIT GAP POLICY PREMIUM WAIVER BENEFIT Our COMPACT 200 option has been conceptualised with medical scheme members in mind because when account shortfalls affect your financial wellbeing, we ll absorb the impact. Complete peace of mind is offered by our comprehensive benefits that fill the gaps in your medical scheme cover. We cover you when your medical scheme does not pay your private healthcare fees in full, refund upfront co-payment costs and lend a helping hand when you need oncology treatment. GAP BENEFIT CO-PAYMENT BENEFIT ONCOLOGY BENEFIT ONCOLOGY OPTIMISER BENEFIT CANCER DIAGNOSIS BENEFIT SUB-LIMIT BENEFIT CASUALTY BENEFIT TRAUMA COUNSELLING BENEFIT ADDITIONAL BENEFIT ACCIDENTAL DEATH BENEFIT Our BASE option provides real cover with real benefits when your medical scheme does not pay your private healthcare fees in full, when the unforeseen expense of a casualty event causes anxiety and lends emotional and financial support when circumstances outside of your control alter the course of your life. GAP BENEFIT CANCER DIAGNOSIS BENEFIT CASUALTY BENEFIT TRAUMA COUNSELLING BENEFIT ADDITIONAL BENEFIT ACCIDENTAL DEATH BENEFIT BENEFIT OVERVIEW Our CO-EVOLUTION option has been expertly combined to provide just the right benefits when unforeseen medical expenses occur. From covering the gap that exists when your medical scheme does not pay your private healthcare fees in full, to benefits for co-payments, casualty events, trauma counselling, cancer diagnosis and accidental death, you can rest assured that we have you covered. GAP BENEFIT CO-PAYMENT BENEFIT CANCER DIAGNOSIS BENEFIT CASUALTY BENEFIT TRAUMA COUNSELLING BENEFIT ADDITIONAL BENEFIT ACCIDENTAL DEATH BENEFIT Our ELITE option has been thoughtfully created with a clear vision to provide elite benefits that offer best-in-class cover to ensure complete peace of mind knowing we have you covered. This option is perfectly suited for individuals who don t compromise on cover. We don t. GAP BENEFIT CO-PAYMENT BENEFIT ONCOLOGY BENEFIT ONCOLOGY OPTIMISER BENEFIT CANCER DIAGNOSIS BENEFIT SUB-LIMIT BENEFIT CASUALTY BENEFIT TRAUMA COUNSELLING BENEFIT REHAB OPTIMISER BENEFIT PREVENTATIVE CARE BENEFIT ADDITIONAL BENEFITS GAP POLICY PREMIUM WAIVER BENEFIT MEDICAL SCHEME CONTRIBUTION WAIVER BENEFIT ACCIDENTAL DEATH BENEFIT Our ACCESS OPTIMISER option has been skilfully designed to provide you with the necessary cover for a medical procedure that is not claimable from your medical scheme, because the procedure is listed as a specific exclusion. GAP BENEFIT (Optional to add) ACCESS OPTIMISER BENEFIT ADDITIONAL BENEFIT ACCIDENTAL DEATH BENEFIT BENEFIT EDGE 200 COMPACT 200 BASE CO-EVOLUTION ELITE ACCESS OPTIMISER OVERALL POLICY LIMIT (OPL) Our gap cover options are subject to OVERALL POLICY LIMITS (OPL s) per year. Subject to an OVERALL POLICY LIMIT (OPL) of R per year. Subject to an OVERALL POLICY LIMIT (OPL) of R per person per year. Subject to an OVERALL POLICY LIMIT (OPL) of R per person per year. Subject to an OVERALL POLICY LIMIT (OPL) of R per person per year. Subject to an OVERALL POLICY LIMIT (OPL) of R per person per year. Our ACCESS OPTIMISER option is subject to an OVERALL POLICY LIMIT (OPL) of R per policy per year or when adding our GAP BENEFIT increases to R per policy per year. GAP BENEFIT Our GAP BENEFIT provides an additional 200% or 500% cover, when you become liable for the difference between what your service providers charge and what your medical scheme pays from your medical scheme hospital benefit for account shortfalls related to the following: Doctors and specialists Dentistry and related procedures Basic radiology Specialised radiology limited to MRI, CT and PET scans Pathology Physiotherapy Consumable items such as surgical gloves, bandages and gauze Medication provided as part of your in- or out-of-hospital event Additional 200% cover. Additional 200% cover. Additional 500% cover. Additional 500% cover. Additional 500% cover. Dentistry and related procedures limited to R per year. Specialised radiology limited to R per year. Dentistry and related procedures limited to R per policy per year. Specialised radiology limited to R per policy per year. Dentistry and related procedures limited to R per policy per year. Specialised radiology limited to R per policy per year. Dentistry and related procedures limited to R per policy per year. Specialised radiology limited to R per policy per year. Dentistry and related procedures limited to R per policy per year. Specialised radiology limited to R per policy per year. Our GAP BENEFIT, providing an additional 500% cover, can be taken voluntarily at an additional premium per month. Dentistry and related procedures limited to R per policy per year. Specialised radiology limited to R per policy per year. 18 THESE POLICIES ARE NON-MEDICAL SCHEME PRODUCTS, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE

21 BENEFIT EDGE 200 COMPACT 200 BASE CO-EVOLUTION ELITE ACCESS OPTIMISER CO-PAYMENT BENEFIT Our CO-PAYMENT BENEFIT covers in- and out-of-hospital medical procedure related and specialised radiology scan co-payments, deductibles or hospital admission fees, represented as either a rand amount or a percentage. ONCOLOGY BENEFIT You are covered when your medical scheme only pays a portion towards your approved oncology treatment such as radiotherapy, chemotherapy, basic and specialised radiology, pathology, specialist consultations, registered oncology facility fees, biological or specialised medication etc. Our ONCOLOGY BENEFIT covers you when your medical scheme only pays a portion towards your service providers accounts. ONCOLOGY OPTIMISER BENEFIT You are covered when your medical scheme provides you with an oncology benefit but applies a rand amount limit from which you can claim per year. Once this rand amount limit is reached, you will be liable to pay all treatment costs thereafter. Our ONCOLOGY OPTIMISER BENEFIT covers your oncology treatment costs when your medical scheme no longer does. Our CO-PAYMENT BENEFIT is limited to R per policy per year. Our ONCOLOGY BENEFIT does not have a benefit limit but is subject to the OPL. Our ONCOLOGY OPTIMISER BENEFIT is limited to R per person per year. Our CO-PAYMENT BENEFIT is limited to R per policy per year. Our CO-PAYMENT BENEFIT does not have a benefit limit but is subject to the OPL. You will also be covered for 1 co-payment up to an amount of R per policy per year, for the voluntary use of a non-dsp. Our ONCOLOGY BENEFIT does not have a benefit limit but is subject to the OPL. Our ONCOLOGY OPTIMISER BENEFIT does not have a benefit limit but is subject to the OPL. GAP COVER PRODUCT RANGE OVERVIEW CANCER DIAGNOSIS BENEFIT Our DIAGNOSIS BENEFIT provides a once-off payment when you are diagnosed with cancer for the first time and the diagnosis aligns to specific qualifying criteria. Our CANCER DIAGNOSIS BENEFIT provides a once-off payment of R , not subject to the OPL. Our CANCER DIAGNOSIS BENEFIT provides a once-off payment of R 5 000, not subject to the OPL. Our CANCER DIAGNOSIS BENEFIT provides a once-off payment of R 5 000, not subject to the OPL. Our CANCER DIAGNOSIS BENEFIT provides a once-off payment of R , not subject to the OPL. SUB-LIMIT BENEFIT Our SUB-LIMIT BENEFIT provides cover when you become liable to settle a portion of your internal prosthesis provider s account, or the service providers accounts relating to your non-pmb day procedure or renal dialysis treatment, as indicated. Our SUB-LIMIT BENEFIT provides cover for your internal prosthesis provider s account, up to R per event with a maximum of R per person per year. Our SUB-LIMIT BENEFIT provides cover for your internal prosthesis provider s account, or the service providers accounts relating to your non-pmb day procedure or renal dialysis treatment, up to R per event with a maximum of R per person per year. You will also be covered for 2 MRI or CT scans up to an amount of R per scan per policy per year, when you become liable to settle a portion of, or the full amount of your service provider s account. THESE POLICIES ARE NON-MEDICAL SCHEME PRODUCTS, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE 19

22 BENEFIT EDGE 200 COMPACT 200 BASE CO-EVOLUTION ELITE ACCESS OPTIMISER CASUALTY BENEFIT Our CASUALTY BENEFIT covers the cost of your casualty event for: Doctors and specialists Basic and specialised radiology Pathology Consumable items such as surgical gloves, bandages and gauze Medication provided as part of your casualty event at the registered medical facility Upfront casualty co-payments or facility fees Our CASUALTY BENEFIT is limited to R per policy per year. Our CASUALTY BENEFIT is limited to R per policy per year. Our CASUALTY BENEFIT is limited to R per policy per year. Our CASUALTY BENEFIT is limited to R per policy per year. Our CASUALTY BENEFIT is limited to R per policy per year. TRAUMA COUNSELLING BENEFIT Our TRAUMA COUNSELLING BENEFIT covers your consultation fees in the event that you witnessed or were directly affected by an act of physical violence or an accident resulting in serious bodily injury or death, when you are diagnosed with a dread disease or are affected by a loved one s diagnosis of a dread disease or death. Our TRAUMA COUNSELLING BENEFIT is limited to R per policy per year. Our TRAUMA COUNSELLING BENEFIT is limited to R per policy per year. Our TRAUMA COUNSELLING BENEFIT is limited to R per policy per year. Our TRAUMA COUNSELLING BENEFIT is limited to R per policy per year. REHABILITATION OPTIMISER BENEFIT Our REHABILITATION OPTIMISER BENEFIT covers your rehabilitation treatment costs when your medical scheme provides you with a rehabilitation benefit for accidental events but applies a rand amount limit or a limit to the number of days you may be admitted from which you can claim per year. Once these limits are reached, you will be liable to pay all treatment costs thereafter. Our REHABILITATION OPTIMISER BENEFIT is limited to R per person per year. You are covered for rehabilitation treatment provided by on-site therapists as well as your stay at a registered sub-acute or step-down facility when your medical scheme no longer does. PREVENTATIVE CARE BENEFIT Our PREVENTATIVE CARE BENEFIT covers your consultation fee or the cost of a Pap smear, prostate screening (PSA test) or full blood count (FBC test) to help diagnose certain cancers. Our PREVENTATIVE CARE BENEFIT is limited to R 500 per policy per year. ADDITIONAL BENEFITS Our GAP POLICY PREMIUM WAIVER BENEFIT covers your Stratum Benefits policy premium in the event of death, permanent disability or forced retrenchment of the Stratum Benefits policy premium payer. Our GAP POLICY PREMIUM WAIVER BENEFIT covers your Stratum Benefits policy premium for 12 months in the event of death, permanent disability or forced retrenchment of the Stratum Benefits policy premium payer, not subject to the OPL. Our GAP POLICY PREMIUM WAIVER BENEFIT covers your Stratum Benefits policy premium for 12 months in the event of death, permanent disability or forced retrenchment of the Stratum Benefits policy premium payer, not subject to the OPL. Our MEDICAL SCHEME CONTRIBUTION WAIVER BENEFIT covers your medical scheme contribution in the event of death or permanent disability of the medical scheme contribution payer. Our MEDICAL SCHEME CONTRIBUTION WAIVER BENEFIT covers your medical scheme contribution for 6 months to a maximum of R per month, in the event of death or permanent disability of the medical scheme contribution payer, not subject to the OPL. 20 THESE POLICIES ARE NON-MEDICAL SCHEME PRODUCTS, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE

23 BENEFIT EDGE 200 COMPACT 200 BASE CO-EVOLUTION ELITE ACCESS OPTIMISER Our ACCIDENTAL DEATH BENEFIT provides a lump sum payment in the event of the accidental death of the principal insured, spouse or dependant, as indicated. ACCESS OPTIMISER BENEFIT Our ACCESS OPTIMISER BENEFIT provides cover when your medical scheme excludes a medical procedure that forms part of a specific list of exclusions, over and above the general exclusions applicable to your medical scheme option, leaving you liable to pay all hospitalisation and related service providers accounts in full. WE COVER You, whether you are the main member or dependant on a medical scheme option. You, as the only individual insured on this option. Our ACCIDENTAL DEATH BENEFIT provides a payment of R in the event of the accidental death of the principal insured or spouse, and R for the accidental death of a dependant, not subject to the OPL. Our ACCIDENTAL DEATH BENEFIT provides a payment of R in the event of the accidental death of the principal insured or spouse, not subject to the OPL. Our ACCIDENTAL DEATH BENEFIT provides a payment of R in the event of the accidental death of the principal insured or spouse, not subject to the OPL. Our ACCIDENTAL DEATH BENEFIT provides a payment of R in the event of the accidental death of the principal insured or spouse, and R for the accidental death of a dependant, not subject to the OPL. Our ACCIDENTAL DEATH BENEFIT provides a payment of R in the event of the accidental death of the principal insured or spouse, not subject to the OPL. Our ACCESS OPTIMISER BENEFIT provides cover for your hospital and service providers accounts up to a specified rand amount limit per medical procedure not covered by your medical scheme. INDIVIDUALS 64 AND YOUNGER We cover you and your spouse on one policy, even if you belong to different medical schemes or medical scheme options, including all dependants registered on your or your spouse s medical scheme option. INDIVIDUALS 65 AND OLDER We cover you and your spouse on one policy, even if you belong to different medical schemes or medical scheme options, or you and one other dependant registered on your medical scheme option. Where either one, or both individuals are 65 and older the 65+ premium will apply, limited to two insured individuals per policy. GAP COVER PRODUCT RANGE OVERVIEW MONTHLY PREMIUM * 64 AND YOUNGER 64 AND YOUNGER 64 AND YOUNGER 64 AND YOUNGER 64 AND YOUNGER Single R 100 Single R 180 Single R 180 Single R 200 Single R 295 Single or Family R * Family R 210 Family R 205 Family R 250 Family R 355 Add Gap Benefit R 65 Single 65+ * Single R 180 R * Single or Family R * Single or Family R * Single or Family R * Single or Family R * Single or Family Add Gap Benefit R 285 R 115 *Limited to one insured individual per policy *Limited to two insured individuals per policy *Limited to two insured individuals per policy *Limited to two insured individuals per policy *Limited to two insured individuals per policy *Limited to two insured individuals per policy THESE POLICIES ARE NON-MEDICAL SCHEME PRODUCTS, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE 21

24 With the essential healthcare needs of the majority of South Africans in mind, we have passionately created a short-term health insurance solution in partnership with Unity Health that focuses on the healthcare needs of individuals from all walks of life. To ensure quality and affordable healthcare remain within your reach, Unity Health has contracted with various private healthcare providers at discounted rates to include benefits for doctor consultations, acute and chronic medication, basic blood tests and x-rays, basic and emergency dentistry, basic eye care and maternity care. In addition, hospitalisation benefits for accidents and emergencies are included to make provision for each individual s constitutional right to receive treatment in either a private of public facility. Not only do we take our responsibility in contributing to the socio-economic development of our country seriously, but also each client s health and wellbeing. We believe a healthy body helps you lead your best life and therefore offer a wellness assessment benefit that provides you with the necessary health checks when you need peace of mind about the status of your health. You also have access to a telephonic assistance programme that offers counselling and advisory services when the storms of life get you down and you need an extra boost to face life head-on. Stratum Health Insure committed to the nation and committed to you.

25 ESSENTIAL PRIMARY PLUS Our ESSENTIAL PRIMARY PLUS option has been created to provide a choice between DAY-TO-DAY and EMERGENCY & ACCIDENTAL benefits because we understand that every individual is unique. Whether belonging to a medical scheme or not, access to the very best essential and affordable health insurance is within your reach, providing cover to you, your spouse and any child dependant of whom you are the parent or legal guardian. Our HEALTH INSURE clients have unlimited access to any Unity Health network doctor nationwide. No upfront payments are required when you visit a network provider because your Stratum Health Insure and Unity Health client card identifies you as a registered client, allowing you to access the benefits that you need. Rest assured that you have found a healthcare partner that not only covers you, but gets you. HEALTH INSURE ESSENTIAL PRIMARY PLUS IN PARTNERSHIP WITH T S & C S APPLY E&OE 23

26 HEALTH INSURANCE FOR INDIVIDUALS OFFERING A CHOICE BETWEEN DAY-TO-DAY BENEFITS, EMERGENCY & ACCIDENTAL BENEFITS OR A COMBINATION OPTION ESSENTIAL PRIMARY PLUS DAY-TO-DAY BENEFITS Our comprehensive and essential DAY-TO-DAY BENEFITS, which can be taken as a standalone benefit option, are provided by Unity Health s network of service providers consisting of approximately doctors, dentists, optometrists as well as various pharmacies, pathologists and radiologists. BENEFIT OPTION DAY-TO-DAY BENEFITS ONLY EMERGENCY & ACCIDENTAL BENEFITS ONLY DAY-TO-DAY AND EMERGENCY & ACCIDENTAL BENEFITS ENTRY AGE PRINCIPAL INSURED SPOUSE MONTHLY PREMIUM ADULT DEPENDANT FULL FULL TIME TIME STUDENTS OVER CHILD DEPENDANT 20 UP AND TO YOUNGER AGE and younger R 315 R 210 R 210 R and older R 465 R and younger R 135 R 75 R 75 R and older R 170 R and younger R 405 R 290 R 290 R and older R 580 R WE COVER You, your spouse and any child dependant of whom you are the parent or legal guardian. Child dependants up to the age of 21 at a child dependant premium and full time students over the age of 21 at an adult dependant premium, provided proof of studies is submitted yearly. You, whether you belong to a medical scheme or not. DAY-TO-DAY BENEFITS DOCTOR VISITS BASIC MEDICAL PROCEDURES ACUTE MEDICATION CHRONIC MEDICATION BASIC BLOOD TESTS & X-RAYS BASIC & EMERGENCY DENTISTRY ACCIDENTAL DENTISTRY BASIC EYE CARE MATERNITY CARE UNIQUE FEATURES You and your loved ones have access to unlimited visits at any Unity Health network doctor. Your network doctor can perform minor medical and surgical procedures in the rooms such as removal of a mole or draining of an abscess. DISPENSING NETWORK DOCTOR NON-DISPENSING NETWORK DOCTOR When you need acute medication for an acute condition or illness, such as chest infection, sinusitis or flu, your dispensing network doctor can provide medication according to a formulary. Acute medication that is provided by your dispensing network doctor in the rooms is unlimited. A non-dispensing network doctor will prescribe acute medication according to a formulary that can be collected at any Mediscor pharmacy, which includes pharmacies such as Clicks and Dis-Chem. Acute medication that is prescribed by your non-dispensing network doctor is limited to R per person per year. Chronic conditions or diseases, such as diabetes, can be treated by your network doctor. Chronic medication can be provided or prescribed by your network doctor according to a formulary, for the following chronic conditions or diseases: Chronic Obstructive Pulmonary Disorder, Diabetes Type 1 & 2, Epilepsy, Hyperlipidemia, Hypertension, Tuberculosis and HIV / AIDS. Your network doctor must refer you for basic blood tests, such as a cholesterol or glucose test, or basic x-rays, such as a chest x-ray during one of your visits. Blood tests and x-rays are subject to an approved list of tariff codes. Basic dental procedures, such as a full mouth assessment, fillings and extractions and emergency dental procedures, such as treatment of an abscess or emergency root canal can be provided by your Unity Health network dentist. Basic and emergency dental procedures are subject to an approved list of tariff codes, limited to R per person per event and R per family every 2 years. Specialised dentistry such as bridgework, crowns, dentures and orthodontic treatment are not covered. When you need urgent dental treatment for an unexpected physical injury that causes loss or damage to your teeth, such as a broken tooth, your network dentist can provide you with treatment to a maximum of R per person per event and R per family every 2 years. Your nearest PPN network optometrist can provide an eye test and prescribe glasses when you need basic eye care. You are covered for 1 eye test per person every year, as well as 1 standard frame to the value of R 195 per person and 1 pair of clear monofocal or bifocal lenses per person every 2 years. Additional optional extras, such as tinting, anti-reflective and scratch resistant coatings are not covered. You may consult with any gynaecologist of your choice when you, the soon-to-be-mom, need one-on-one consultations to get advice about your health during your pregnancy. Our benefit provides 2 maternity check-ups including ultrasound scans during your visits, limited to R per policy per year. 24 T S & C S APPLY E&OE

27 EMERGENCY & ACCIDENTAL BENEFITS Our unique EMERGENCY & ACCIDENTAL BENEFITS, which can be taken as a stand-alone benefit option, are provided by your nearest, registered private hospital and the hospital s casualty facility. When you are admitted into a private facility for a planned medical procedure, cover is not applicable. EMERGENCY & ACCIDENTAL BENEFITS OVERALL POLICY LIMIT (OPL) HOSPITALISATION DUE TO AN EMERGENCY HOSPITALISATION DUE TO AN ACCIDENT CASUALTY FACILITY 24 HOUR MEDICAL EMERGENCY SERVICES ACCIDENTAL DEATH BENEFIT ESSENTIAL WELLNESS BENEFITS UNIQUE FEATURES Each benefit has its own rand amount limit but when combined cannot exceed R per policy per year. You are covered at your nearest private hospital when you need immediate treatment in the event of a medical emergency that requires you to be stabilised before being transferred to a public facility, should you need further treatment. An emergency is an event or unexpected health condition that can result in death or serious bodily impairment if not treated immediately, such as a heart attack or stroke. Our benefit is limited to R per person per event, subject to the OPL. We cover you when you need immediate treatment due to accidental impact, which results in severe physical injury. Examples of accidents are motor vehicle accidents where you sustained severe injuries, injuries from a crime or a snake bite. Our benefit is limited to R per person per event, subject to the OPL. When you need immediate treatment for minor physical injury that is caused by an external force, you are covered at a private hospital s casualty facility to a benefit limit of R per person per event, subject to the OPL. Visits to a casualty facility can be due to minor injuries caused by vehicle accidents or from working with factory machinery. When life happens and every second matters, our national emergency partners will be standing by to provide essential emergency assistance. You have access to: Our national 24-hour emergency contact centre Emergency transport services by air or road Ambulance transfers between hospitals Telephonic medical advice Repatriation of a loved one s mortal remains within the borders of South Africa Our benefit offers a lump sum payment when you are faced with unexpected change due to the loss of a loved one. We provide a payment of R in the event of the accidental death of the principal insured or spouse registered on the health insurance policy, not subject to the OPL. Our ESSENTIAL WELLNESS BENEFITS provide access to a wellness assessment and a telephonic assistance programme consisting of counselling and advisory services that are automatically included when you join our DAY-TO-DAY-, or DAY-TO-DAY AND EMERGENCY & ACCIDENTAL BENEFITS health insurance option, because we believe a healthy body and a focused mind help you lead your best life. Our stand-alone EMERGENCY & ACCIDENTAL BENEFITS health insurance option includes access to only our ESSENTIAL ASSISTANCE PROGRAMME (EAP) when sound advice is needed most. HEALTH INSURE COVER ESSENTIAL PRIMARY PLUS ESSENTIAL WELLNESS BENEFITS WELLNESS ASSESSMENT BENEFIT UNIQUE FEATURES Your nearest Dis-Chem pharmacy provides the necessary wellness assessment when you need peace of mind about the status of your health. The wellness assessment is done by registered nurse practitioners at a Dis-Chem clinic in an enclosed private consultation room. Our WELLNESS ASSESSMENT BENEFIT includes the following health checks: Blood pressure Cholesterol Glucose levels Body Mass Index (BMI) Waist circumference HIV including pre- & post-test counselling Our benefit is limited to 1 assessment per person per year. ESSENTIAL ASSISTANCE PROGRAMME (EAP) When the storms of life get you down and you need advice and guidance, you have access to our ESSENTIAL ASSISTANCE PROGRAMME (EAP) that provides unlimited telephonic advisory and counselling services. Our EAP benefit is available 24/7 and includes advice and counselling for: Trauma counselling HIV counselling Legal advice Financial advice When you need an extra boost to face life head-on, personal face-to-face counselling can be arranged for your own pocket. T S & C S APPLY E&OE 25

28 THE CLEAR PRINT We believe in consistently communicating in a simple, clear and concise manner and have therefore removed the insurance jargon so that you don t have to read between the lines. YOUR GAP COVER POLICY WAITING PERIODS From the first day your cover starts, waiting periods will apply before you are able to claim from specific policy benefits. 3 MONTH GENERAL WAITING PERIOD Within the first 3 months of cover a general waiting period will apply, where no claims can be submitted unless you are claiming for an injury resulting from an accident caused by physical impact. 12 MONTH PRE-EXISTING CONDITION WAITING PERIOD Within the first 12 months of cover a waiting period for pre-existing medical conditions will apply, where no claims can be submitted for a procedure, surgery, treatment or an investigation relating to any illness or condition for which you received advice or treatment 12 months prior to your cover start date. YOUR HEALTH INSURE POLICY WAITING PERIODS From the first day your cover starts, waiting periods will apply to the DAY-TO-DAY BENEFITS on your ESSENTIAL PRIMARY PLUS option. 2 MONTH GENERAL WAITING PERIOD Within the first 2 months of cover a general waiting period will apply to all benefits. 9 MONTH MATERNITY CARE WAITING PERIOD Within the first 9 months of cover a waiting period will apply to the MATERNITY CARE benefits. 12 MONTH BASIC EYE CARE & CHRONIC MEDICATION WAITING PERIOD Within the first 12 months of cover a waiting period will apply to the BASIC EYE CARE and CHRONIC MEDICATION benefits. EXCEPTIONS TO THE RULE A 2 Month General Waiting Period applies to the ESSENTIAL WELLNESS BENEFITS on your ESSENTIAL PRIMARY PLUS option. Waiting periods do not apply to the EMERGENCY & ACCIDENTAL BENEFITS on your ESSENTIAL PRIMARY PLUS option. 26 OUR GAP COVER POLICIES ARE NON-MEDICAL SCHEME PRODUCTS, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE

29 GAP COVER BENEFIT EXCLUSIONS WHAT OUR BENEFITS DO NOT COVER GAP BENEFIT DOES NOT COVER 1) Service providers accounts; a) where the shortfall is more than what our gap benefit provides. b) that are covered in full or covered as a concession from your medical scheme hospital benefit, where no shortfalls exist. c) where your medical scheme did not pay a portion towards the account, or towards an individual line item on the account from your medical scheme hospital benefit. d) where your medical scheme paid a portion of, or the full amount of the account from your medical scheme savings account or day-to-day benefit, also known as a block or insured benefit. e) where your medical scheme benefit limit is exceeded. f) where the treatment dates differ from the date of your in- or out-of-hospital medical event. 2) Consultations in the rooms nor consultations prior to, or following an in- or out-ofhospital medical event. 3) A private upfront fee charged by your doctor or specialist which you are responsible to pay and cannot claim from your medical scheme. 4) Paid by you whilst you are in your medical scheme self-payment gap. 5) Hospital accounts including, but not limited to theatre and ward fees. 6) Specialised radiology except for MRI, CT and PET scans. 7) Consumable items and medication which your medical scheme did not pay during your in- or out-of-hospital medical event, prescription medication or medication provided to take home. 8) Allied service providers accounts for diagnostic, technical, therapeutic, direct patient care and support services, such as occupational and speech therapy unless our benefit specifically makes provision for cover. CO-PAYMENT BENEFIT DOES NOT COVER 1) Co-payments or deductibles applied; a) where you failed to obtain pre-authorisation or an appropriate service provider referral. b) where you had not followed your medical scheme rules. c) for the voluntary use of a hospital, day clinic or service provider that does not form part of your medical scheme s network, unless our benefit specifically makes provision for cover. 2) Split billing invoicing, where a private upfront fee is charged by your service provider which you are responsible to pay and cannot claim from your medical scheme. 3) Co-payments applied for chronic, acute, formulary or non-formulary medication. ONCOLOGY BENEFITS DO NOT COVER 1) Cancer treatment costs and biological medication not approved by your medical scheme as part of your initial or ongoing oncology treatment plan. 2) Service providers accounts where your medical scheme paid a portion of, or the full amount of the account from your medical scheme savings account or day-to-day benefit, also known as a block or insured benefit. 3) Service providers accounts; a) where you had not followed your medical scheme rules. b) for the voluntary use of a service provider that does not form part of your medical scheme s network. 4) Our CANCER DIAGNOSIS BENEFIT does not cover a first-time diagnosis; a) when the cancerous cells have not invaded surrounding or underlying tissue. b) for cancers of the skin except cancerous moles that have invaded underlying tissue. c) for Stage 1 prostate or breast cancer described as T1a, N0, M0 or G1. (T) refers to the size of the tumour, (N) to the number of lymph nodes affected, (M) to metastasis and (G) to the grade or aggressiveness of cancer. d) if your diagnosis is made before the first day your cover starts or whilst your 3 Month General Waiting Period applies. e) of a second or subsequent diagnosis. f) after the benefit ceased at age 65. SUB-LIMIT BENEFIT DOES NOT COVER 1) Service providers accounts; a) where your medical scheme applied a sub-limit or annual limit to in- or outof-hospital medical procedures, treatment or investigations except for internal prostheses, non-pmb day procedures, renal dialysis and MRI & CT scans, where applicable. b) where your medical scheme s sub-limit or annual limit is exhausted at the time of the event and your medical scheme did not pay a portion towards your service provider s account, unless our benefit specifically makes provision for cover. 2) Renal dialysis treatment costs not approved by your medical scheme as part of your initial or ongoing dialysis treatment plan, where applicable. 3) Renal dialysis treatment where you had not followed your medical scheme rules and / or for the voluntary use of a service provider that does not form part of your medical scheme s network, where applicable. CASUALTY BENEFIT DOES NOT COVER 1) A casualty event that was not due to an accident and / or did not require immediate treatment for physical injury, which resulted from an external force outside of the body due to impact with someone or something. 2) Service providers accounts where your medical scheme provided a casualty benefit and paid the accounts in full from your medical scheme hospital benefit. 3) Service providers accounts where the treatment dates differ from the date of the casualty event, except for return visits to the registered medical facility where followup treatment is required as a result of the initial casualty event. 4) Medication prescribed or provided to take home. TRAUMA COUNSELLING BENEFIT DOES NOT COVER 1) Registered counsellor s, clinical psychologist s or psychiatrist s accounts if you; a) did not witness, or were not directly affected by an act of physical violence or an accident resulting in serious bodily injury or death. b) were not diagnosed with a dread disease, or were not affected by a loved one s diagnosis of a dread disease or death. 2) Service providers accounts where your medical scheme provided a trauma counselling benefit and paid the accounts in full from your medical scheme hospital benefit. 3) The fee charged by your counsellor, clinical psychologist or psychiatrist if they are not registered with a recognised South African regulatory body. REHABILITATION OPTIMISER BENEFIT DOES NOT COVER 1) Rehabilitation admission or treatment costs not approved by your medical scheme as part of your initial or ongoing rehabilitation treatment plan. 2) Service providers accounts; a) where your admission or treatment is not due to a physical injury resulting from an accident. b) where therapy or treatment is provided off-site or after discharge. c) for counsellors, clinical psychologists or psychiatrists. 3) Rehabilitation admission or treatment costs where you had not followed your medical scheme rules and / or for the voluntary use of a service provider that does not form part of your medical scheme s network. 4) Rehabilitation facilities providing services other than physical rehabilitation. 5) The fee charged by your service providers if they are not registered with a recognised South African regulatory body. PREVENTATIVE CARE BENEFIT DOES NOT COVER 1) Service providers accounts where your medical scheme provided a preventative screening benefit and paid the accounts in full from your medical scheme hospital benefit. 2) Preventative tests except for a pap smear, prostate screening (PSA test) or full blood count (FBC) to help diagnose certain cancers. ADDITIONAL BENEFITS GAP POLICY PREMIUM WAIVER, MEDICAL SCHEME CONTRIBUTION WAIVER & ACCIDENTAL DEATH BENEFITS DO NOT COVER 1) Events where disability is temporary or where retrenchment is voluntary. 2) Death, permanent disability or forced retrenchment of an insured person if that person is not noted as the gap policy premium payer or the medical scheme contribution payer, where applicable. 3) Forced retrenchment, permanent disability and death where the premium or contribution payer s details changed to another payer s details 3 months prior to the event, except for accidental permanent disability or death. 4) Death due to natural causes applicable to our ACCIDENTAL DEATH BENEFIT only. ACCESS OPTIMISER BENEFIT DOES NOT COVER 1) Medical procedures listed as specific exclusions by your medical scheme that do not form part of our list of medical procedures covered. 2) Service providers accounts; a) where your medical scheme provides a benefit and paid a portion towards the account. b) where your medical scheme provides a sub-limit or annual limit from which you can claim for in-hospital medical procedures, but is exhausted at the time of the event. c) where your chosen service providers charge a rate that exceeds the rand amount limit we provide. d) that are covered as a concession from your medical scheme hospital benefit, although the medical procedure forms part of the medical scheme s exclusions. THE CLEAR PRINT OUR GAP COVER POLICIES ARE NON-MEDICAL SCHEME PRODUCTS, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE 27

30 GENERAL EXCLUSIONS APPLICABLE TO YOUR GAP COVER POLICY We do not cover service providers accounts for related medical procedures and / or treatment, hospitalisation, illness, disease, loss, damage, death, bodily injury or liability that is caused by or results from: 1) An event where the claimant is not an insured person at the time of the event, unless a benefit specifically makes provision for cover. 2) Medical scheme exclusions where no underlying cover exists, unless a benefit specifically makes provision for cover. 3) An event where a benefit limit or an Overall Policy Limit (OPL) has been reached. 4) An event where the policy does not provide the relevant benefit to claim from. 5) An event where pre-authorisation was not obtained from the medical scheme or where medical scheme rules were not followed. 6) An event where the use of a hospital, day-clinic or service provider was voluntary and the service provider does not form part of the medical scheme s network, unless a benefit specifically makes provision for cover. 7) An event that occurs during a policy waiting period, unless otherwise specified. 8) Maxillo-facial surgery and related medical conditions and / or medical procedures unless due to accidental impact resulting in severe physical injury. 9) Dental implants, orthodontic, prosthodontic or cosmetic dentistry. 10) External prostheses or appliances such as artificial limbs, wheelchairs and crutches. 11) Robotic surgery, specialised mechanical or computerised appliances and equipment. 12) Artificial insemination, infertility treatment or contraceptives except for tubal ligation and vasectomies. 13) Obesity. 14) Non-medically necessary reconstructive cosmetic surgery. 15) Breast reconstruction performed as a second or subsequent reconstruction. 16) Home nursing or admission to a step-down facility such as a frail care centre, unless a benefit specifically makes provision for cover. 17) Depression, insanity, emotional or mental illness or any stress-related conditions. 18) Costs associated with supporting medical reports that assist in the finalisation of a claim. 19) Routine physical, diagnostic procedures or examination where there are no objective indications of impairment in normal health. 20) Expenses incurred for transport charges or for services rendered whilst being transported in an emergency vehicle, vessel or aircraft. 21) Riots, wars, political acts, public disorder, terrorism, civil commotions, labour disturbances, strikes, lock-out, or any attempted such acts. 22) A deliberate criminal or fraudulent act or any illegal activity conducted by you or a member of your household which directly or indirectly results in loss, damage or injury. 23) Attempted suicide, intentional self-injury and deliberate exposure to exceptional danger except in an attempt to save a human life. 24) An event where the use of drugs or alcohol is involved. 25) Active military, police and police reservist activities whilst on active duty. 26) Nuclear weapons material, ionising radiations or contamination by radioactivity from any nuclear fuel, nuclear waste or from the combustion of nuclear fuel that includes any self sustaining process of nuclear fission. 27) Events that occur for which the actual damage is provided for by legislation, including contractual liability and consequential loss. 28) Discounts negotiated by an insured person directly with a service provider where reimbursement of a claim will enrich the insured person. 29) Non-disclosure of material information that is likely to affect the assessment or acceptance of risk. GENERAL EXCLUSIONS APPLICABLE TO YOUR HEALTH INSURE POLICY We do not cover service providers accounts for related medical procedures and / or treatment, hospitalisation, illness, disease, loss, damage, death, bodily injury or liability that is caused by or results from: 1) An event where the claimant is not an insured person at the time of the event. 2) An event where a benefit limit or an Overall Policy Limit (OPL) has been reached. 3) An event where the health insurance policy does not provide the relevant benefit to claim from. 4) An event where pre-authorisation or an appropriate service provider referral was not obtained and / or where the Unity Health guidelines or protocols were not adhered to. 5) An event where a service provider was utilised that does not form part of the Unity Health network, unless otherwise specified. 6) An event where healthcare services, such as consultations, basic medical procedures, acute and chronic medication and basic dentistry do not form part of Unity Health s list of approved services, tariff codes or benefits. 7) An event that occurs during a policy waiting period, unless otherwise specified. 8) A hospital event that was not due to an accident or an emergency. 9) A hospital event for a planned medical procedure. 10) Costs incurred for the voluntary stay at a private facility following stabilisation due to an emergency. 11) Reconstructive cosmetic surgery and / or maxillo-facial surgery, including related medical conditions and procedures, if not performed during an authorised hospital event resulting from an accident. 12) Contact lenses. 13) External prostheses or appliances, such as artificial limbs. 14) Artificial insemination, infertility treatment or contraceptives. 15) Robotic surgery, specialised mechanical or computerised appliances, equipment and all related service providers accounts. 16) Routine physical, diagnostic procedures or examination where there are no objective indications of impairment in normal health. 17) Riots, wars, political acts, public disorder, terrorism, civil commotions, labour disturbances, strikes, lock-out, or any attempted such acts. 18) A deliberate criminal or fraudulent act or any illegal activity conducted by you or a member of your household which directly or indirectly results in loss, damage or injury. 19) Attempted suicide, intentional self-injury and deliberate exposure to exceptional danger except when attempting to save a human life. 20) An event where the use of drugs or alcohol is involved. 21) Participation in: a) Active military, police or police reservist duty. b) Aviation other than as a passenger. c) Hazardous, competitive or professional sports or activities. d) Any form of race or speed test, other than on foot or involving any non-mechanically propelled vehicle vessel craft or aircraft. 22) Nuclear weapons material, ionising radiations or contamination by radioactivity from any nuclear fuel, nuclear waste or from the combustion of nuclear fuel that includes any self-sustaining process of nuclear fission. 23) Events that occur for which the actual damage is provided for by legislation, including contractual liability and consequential loss. 24) Non-disclosure of material information that is likely to affect the assessment or acceptance of risk. 28 OUR GAP COVER POLICIES ARE NON-MEDICAL SCHEME PRODUCTS, PROVIDING BENEFITS THAT CANNOT BE COMPARED TO OR SUBSTITUTED FOR MEDICAL SCHEME MEMBERSHIP T S & C S APPLY E&OE

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