1. BENEFICIARIES 2. MEMBERSHIP

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1 RULES, REGULATIONS, CONTRIBUTIONS AND BENEFITS OF THE FURNMED SICK BENEFIT SOCIETY hereinafter referred to as ( The Society or The Furnmed Sick Benefit Society ) 1. BENEFICIARIES A member in good standing and a member s registered dependants, are eligible for specified benefits where medical services are rendered within the Republic of South Africa. Membership of the Society is restricted to: 2. MEMBERSHIP Employees who are actively employed in the Furniture, Bedding and Upholstery Manufacturing Industry and Curtain Manufacturing Industry and who are employed by employers who are members of the Furniture, Bedding and Upholstery Manufacturing Association and the Curtain Makers and Allied Products Association; and Employers of such employees; and Employees who were members of the Society immediately prior to permanent retirement from the Industry due to old age, ill health or disability. 3. MEMBERSHIP CATEGORIES Dependant on the current or past status of the member in the Industry the following membership categories are applicable: Compulsory Members CEPPWAWU members and all other employees who are not members of the National Union of Furniture and Allied Workers of South Africa (NUFAWSA) or any other Trade Union who are actively employed in the Furniture, Bedding and Upholstery Manufacturing Industry and Curtain Manufacturing Industry and whose activities and minimum wages are defined in the Industry s Collective Agreement and are employed by employers who are members of Employer Organisations who are party to the Industry s Collective Agreement. Voluntary members CEPPWAWU members and all other employees who are not members of the National Union of Furniture and Allied Workers of South Africa (NUFAWSA) or any other Trade Union who are directly associated with the Furniture, Bedding and Upholstery Manufacturing Industry and Curtain Manufacturing Industry but whose activities and minimum wages are not defined in the Industry s Collective Agreement. Such persons must be employers or work for employers who are members of Employer Organisations, who are party to the Industry s Collective Agreement. 1

2 Continuation Members Furnmed Sick Benefit Society members who have permanently retired from the Furniture, Bedding and Upholstery Manufacturing Industry or the Curtaining Manufacturing Industry due to old age (Sixty Five [65 years of age or more) or due to ill health or permanent disability In order to qualify as a continuation member, such Furnmed Sick Benefit Society members must have contributed to the Furnmed Sick Benefit Society regularly, for at least five (5) years, immediately prior to permanent retirement and applied for continuation membership within three (3) months of such retirement. Registered spouses of deceased continuation members, subject to application, automatically qualify for continuation membership of the Society. Dependants are defined as follows: 4. DEPENDANTS Adult Dependants The following persons are regarded as being adult dependants, provided that they are registered with the Society and are not members or registered dependants of a member of any other Medical Scheme. * A member s spouse/s, irrespective of their age. Child Dependants The following persons are regarded as being child dependants, provided that they are registered with the Society and are not members or registered dependants of a member of any other Medical Scheme. * A member s biological child, stepchild, legally adopted child or a child who has been placed in the legal custody of a member or the member s spouse. All such children must be under the age of twenty one (21) years and be unmarried, unemployed or be full-time scholars or students. * A member s child who is over the age of twenty one (21) years and is a full-time scholar or student of a recognised Educational Institution may remain registered with the Society as a minor dependant up to the age of twenty four (24) years and eleven (11) months, subject to acceptable confirmation to this effect being submitted to the Society annually, or as and when required by the Society. * Any member s child, irrespective of age, who it totally dependant on, and supported by the member because such a child dependant has been certified as being so mentally and/or physically disabled that they are incapable of supporting themselves. Such a child dependant s maximum income shall not exceed the appropriate maximum basic Social Pension prescribed by regulations as progulmated in terms of the Social Pensions Act, 1973 (Act No. 37 of 1937). The Society must be presented with acceptable medical certification as to such child dependant s disability/s as and when required by the Society. Extraordinary Dependants The following persons are defined as extraordinary dependants provided that they are registered with the Society and are not members or registered dependants of a member of any other Medical Scheme: * Any person who is totally dependant on a member, irrespective of age, and who is not defined as an adult dependant or a child dependant. The admission of such extraordinary dependants to the Society shall be at the sole discretion of the Society s Management Committee. 2

3 5. MEMBERSHIP CARDS A membership card shall be issued to every member of the Society which will serve as evidence of membership of the Society provided that the member has completed the required application form for such a membership card. This membership card must be made available and presented to any person/s or institution rendering a service or supplying goods to a member or a member s registered dependant/s for costs for which the Society may be wholly or partially liable. Membership cards remain the property of the Society at all times and must be returned to the Society on termination of membership. Lost cards will only be replaced by the Society at a cost of R25-00 (Twenty Five Rand), which the member must pay to the Society before a replacement card is issued. A member or a member s registered dependants are the only persons permitted to use a Society membership card. The Society shall not be obliged to issue membership cards to members until at least thirteen (13) weeks of contributions have been paid to the Society. Membership cards when issued will only be valid for a specific period which will usually be for the duration of a specific benefit year. The Society will issue new membership cards to all valid members prior to 31 December each year for the forthcoming benefit year. 6. CHANGE IN MEMBERSHIP DETAILS The Society must be advised immediately when there is any change to a member or registered dependants particulars. To register or deregister dependants, certified copies of any relevant documentation must be presented to the Society, eg. identity documents, marriage certificates, birth certificates, death certificates, divorce orders, etc. must accompany any such application. 7. CONTINUATION MEMBERSHIP Society members who permanently retire from the Industry due to old age (Sixty Five [65] years of age or more), ill health or permanent disability may apply to the Society to become continuation members. The Management Committee shall determine from time to time the appropriate retirement age and the contributions payable by such members. The Management Committee of the Society shall also have the right to determine what benefits shall be made available to such members. Consideration for continuation membership will only be given to members who have contributed to the Society regularly over a period of no less than five (5) years immediately prior to permanent retirement, and have applied for continuation membership within three (3) months of permanently retiring from the Industry. 3

4 Members applying for continuation membership will be obliged to provide any documentary proof needed by the Society to establish the following: Age identity document, birth certificate, etc. ILL Health and Disability the necessary documentary confirmation from Medical Practitioners. Proof of Prior Membership - proof of the period of prior membership of the Society. 8. MINIMUM BENEFIT QUALIFICATION PERIODS A minimum of thirteen (13) weeks of paid contributions is required before a member or a member s registered dependants qualify for Society benefits with the exception of in-patient maternity hospitalisation benefits where a minimum of nine (9) months of paid contributions is required for a female member or a male member s registered female spouse/s. The Society shall not be obliged to afford a member or a member s registered dependants benefits until such time as the above contributions have been paid to the Society. In deserving cases the Society or the Society s Management Committee, at their sole discretion, may waive or reduce a specified minimum benefit qualification period. See Annexure B for detailed benefit qualification periods. 9. BENEFIT LIMITS Members in good standing and such member s registered dependants shall be afforded benefit limits as specified in Annexure B and in terms of the rules and regulations of the Society as determined from time to time by the Society s Trustees. In deserving cases the Society or the Society s Trustees, at their sole discretion, may authorise the payment of benefits where a member s allocated benefit limits have been exhausted. All payment of such benefits shall be regarded as being ex-gratia payments. See Annexure B for detailed benefit limits. 10. MAXIMUM REFUND TARIFFS All services and treatment for which the Society accepts liability shall only be paid for to a maximum of refund tariffs as determined from time to time by the National Health Reference Price List (NHRPL) or any representative body of Medical Schemes recognised and accepted by the Society or in terms of maximum refund tariffs as determined by the Society s Management Committee from time to time. The Society or the Society s Trustees, at their sole discretion, may authorise the payment of benefits where the amount claimed exceeds predetermined refund tariffs. All payment of such benefits shall be regarded as being ex-gratia payments. The Society makes use of the Maximum Medical Aid Price (M.M.A.P) for all medication, prescribed out of hospital and pays only for generic medication if available and as a suitable alternative to patent medicine. 4

5 11. ALLOCATED SERVICE PROVIDERS In order to qualify for certain Society benefits, members and their registered dependants may be required to make use of allocated Service Providers, if so allocated by the Society. The Society shall not be liable for any costs incurred by members, for whatever reason, if members or members registered dependants fail to make use of allocated Service Providers. Members and their registered dependants will only be afforded Specialist Medical Practitioner benefits subject to predetermined limits if they have been referred to such Specialist Medical Practitioners by their allocated Service Provider. 12. CO-PAYMENTS OR LEVIES The Society may determine, from time to time, that a member be required to make a co-payment or pay a levy for any service, treatment or goods supplied to a member or a member s registered dependants by any Service Provider. 13. BENEFIT YEAR A Society s Benefit Year commences on the 1 st of January each year and ends on the 31 st of December each year. 14. BENEFIT TRANSFERS Benefits, whether claimed for or not, are not transferable from one benefit year to another or from one benefit class to another. 15. PRO-RATA BENEFITS During any benefit year the Society will allocate benefit limits to members and their registered dependants on a pro-rata basis according to the member s membership of the Society during the course of the member s first benefit year of membership of the Society, where applicable. Such pro-rated benefits shall be determined from the first (1 st ) day of the month that a member joins the Society. Members who de-register dependants during the course of a benefit year, benefits will be reduced, where applicable, on a pro-rata basis for the balance of the benefit year. Benefits which are so reduced, will be reduced from the first (1 st ) day of the month following the month of de-registration of a dependant. 16. BENEFIT CLASSES There are twenty (20) benefit classes from which benefits may be claimed, subject to annual benefit limits, where applicable. These benefit classes are as follows: General Practitioner Benefits Specialist Practitioner Benefits Out of Network Benefits Prescribed Acute and Chronic Medication Benefits Society Approved Chronic Medication Benefits Specialised Radiology Benefits Radiology Benefits Pathology Benefits 5

6 In-patient Hospitalisation Benefits Alternatives to Hospitalisation Benefits Ambulance and Emergency Services Benefits Dentistry Benefits Specialised Dentistry Benefits Denture Benefits Optical Benefits Optical Surgery Benefits Remedial Therapy Benefits Specialised Treatment Benefits Prosthetic Benefits Appliances and Orthopedic Supplies Benefits See Annexure B for detailed Benefits and Benefit Classes. 17. PROCEDURE FOR CLAIMING BENEFITS All claims for benefits for medical services rendered must be accompanied by a properly and fully completed claim form signed by both the member and the member s employer (if applicable). All supplier accounts must be signed by the member and endorsed with the member s membership number. Where accounts have been paid for by the member, the original receipt must accompany the original account and a claim form. A separate claim form must be completed for each different supplier s accounts. Prescriptions for medication dispensed or a certified copy thereof must be signed by the member and endorsed with the member s membership number. In cases of assault, a certified copy of the report made to the South African Police Services and an affidavit must accompany all related account/s and claim form/s. All supplier accounts must clearly state the following details: The member s name, the member s membership number, the patient s name, the nature of the patient s illness or injury and the dates for which services were rendered. The nature and cost of services rendered and goods received. Details of all other services, treatment, procedures, and BHF tariff code/s. 6

7 18. EX-GRATIA BENEFITS Notwithstanding anything contained in these rules and regulations, the Society or the Society s Trustees may, at their sole discretion, in deserving cases, grant ex-gratia benefits to members from time to time, on such terms and conditions as they may determine. Applications for ex-gratia benefits must be made in writing and addressed to the Society. Such applications must be accompanied by all relevant supporting documentation, if any. All applications for ex-gratia benefits must be fully motivated and stipulate the reason/s why such assistance is required. 19. EXTENDED BENEFITS A member who has contributed to the Society for more than thirteen (13) weeks and who becomes unemployed, may receive Society benefits for a further period of four (4) weeks from the date of termination of employment without the payment of contributions. An unemployed member may apply to the Society to contribute and remain as a member of the Society for a further period not exceeding two (2) months. The contributions payable by the member for such extended benefits shall be based on the member s and employer s contributions (if applicable) at time of termination of employment. Contributions for these extended benefits must be paid for in advance, to the Society. 20. SUSPENSION OF BENEFITS The benefits of members whose contributions are in arrears may be suspended by the Society until such time as all unpaid contributions are paid up to date, in full. Such members will be advised in writing of the Society s intention to suspend their benefits if the payment of arrear contributions is not paid by a specific date as determined by the Society. The Trustees of the Society shall have the right to suspend the payment of benefits to any member or member s registered dependants if it is found that a member or any of a member s registered dependants fraudulently claimed benefits from the Society. The Society s Trustees will determine the period, what type of benefits and for whom benefits are suspended. 21. TERMINATION OF BENEFITS Benefits for compulsory and voluntary members and their registered dependants who have qualified for benefits terminate four (4) weeks after such members become unemployed in the Furniture, Bedding and Upholstery Manufacturing Industry or the Curtaining Manufacturing Industry, and no benefits are payable for any services, goods or treatment rendered after that date. Members whose contributions are in arrears and after notification from the Society fail to pay such arrear contributions, benefits will be terminated by the Society. Should any compulsory or voluntary member s, employer s membership of the Furniture, Bedding and Upholstery Manufacturers Association or the Curtain Makers and Allied Products Association be terminated for whatever reason such member s membership of the Society shall also cease from that date. 7

8 22. CONTRIBUTIONS The Society s Trustees will determine the contributions payable in respect of the Society s various membership categories from time to time. The following may be considered by the Society s Trustees when determining member contributions: The member s membership category, e.g. compulsory, voluntary or continuation. The benefits afforded to each membership category. The member s wages/salary, pension or total income. The type of dependant which is registered with the Society, eg. adult dependant, child dependant or extraordinary dependant. The number of the member s registered dependants. The member s chosen benefit option (only if there is more than one benefit option available). The member s period of membership of the Society (only in respect of continuation members). 23. REFUND OF CONTRIBUTIONS The Society shall not be obliged to refund any contributions made, irrespective of whether benefits were claimed for or not. Contributions erroneously paid to the Society are refundable on written application. 24. MEDICAL EXAMINATIONS The Society s Trustees may at any time require a member or any of the member s registered dependants to undergo a medical examination at the Society s expense by any Medical Practitioner which the Society may nominate. 25. ADMINISTRATOR/S The Administrator of the Society shall be the Furniture Bargaining Council. The Society s Trustees at their sole discretion shall determine from time to time who shall be the Society s Administrator/s and what fee/s shall be paid to the elected Administrator/s for the rendering of administrative services to the Society. 8

9 1) GENERAL PRACTITIONERS Consultations & Treatment Out of hospital FURNMED SICK BENEFIT SOCIETY Limited to seven (7) visits per beneficiary per annum. Benefits for more than 7 (seven) general practitioner visits per beneficiary will be considered only on special request with proper motivation for beneficiaries who are registered with Prime Cure Health for chronic illnesses, e.g. hypertension, diabetes, cardiac diseases, etc. Prime Cure Medi Centres or Prime Cure appointed Network Doctors General Practitioner benefits are only available to registered beneficiaries from Prime Cure Medi Centres or Prime Cure appointed Network Doctors. No General Practitioner benefits are afforded to registered beneficiaries for routine visits for whatever reason if registered beneficiaries fail to make use of Prime Cure Medi Centres or Prime Cure appointed Network Doctors for these services. 2) SPECIALIST PRACTITIONERS Consultations, Treatment, Prescribed Medication - Out of hospital R per registered family, per benefit year Any Service Provider A maximum of 100% of NHRPL Scale of Benefit costs for consultations, examinations, treatment and the cost of Specialist Practitioner prescribed medication. No Specialist Medical Practitioner benefit costs are paid for by the Society unless the member or the member s registered dependants were referred to a Specialist Practitioner by a Prime Cure Medi Centre or a Prime Cure appointed Network Doctor. 3) OUT OF ALLOCATED SERVICE PROVIDER NETWORK - ESSENTIAL EMERGENCY/TRAUMA TREATMENT Consultations, Treatment, Prescribed Medication - Out of hospital R per registered family, per benefit year Any Service Provider Outside of allocated Service Provider Network essential emergency treatment benefits includes consultations, treatment and prescribed medication will only be paid for by the Society if the Society deems the treatment of registered beneficiaries to have been essential emergency/trauma treatment. Members must revert back to their Prime Cure Medi Centre or Prime Cure appointed Network Service Provider for further treatment of any ailment which necessitated emergency treatment outside of the Prime Cure appointed Network of Service Providers. 9

10 4) GENERAL PRACTITIONER - PRESCRIBED MEDICATION & INJECTION MATERIAL Acute & Chronic Medication Out of hospital Unlimited Prime Cure Medi Centres or Prime Cure appointed Network Doctors All out of hospital General Practitioner prescribed acute and chronic medication must be obtained from Prime Cure Medi Centres or Prime Cure appointed Network Doctors. Note that this medication is dispensed according to a fixed formulary. NB: No General Practitioner prescribed medication benefits are afforded to registered beneficiaries who do not make use of Prime Cure Medi Centres or Prime Cure appointed Network Doctors to obtain prescribed medication. 4A) SOCIETY APPROVED CHRONIC MEDICATION Non-EDL Chronic Medication Out of hospital R per registered family, per benefit year Medipost Pharmacy Specialised chronic medication which is not available on prime Cure s EDL (Essential Drug List) or can not be substituted by medication on Prime Cure s EDL may be obtained by registered beneficiaries from their Prime Cure Service Provider or from the Society s Offices once authorised by Prime Cure Head Office (Pharmacy Department) and the Society. All applications to make use of non-edl chronic medication must be directed by the patient s attending Prime Cure appointed Service Provider to Prime Cure Head Office together with suitable written motivation. On recommendation from Prime Cure Head Office, the Society at its sole discretion may authorise benefits for non-edl chronic medication. 5) RADIOLOGY OUT OF HOSPITAL X-Rays R per registered family, per benefit year Any Service Provider, subject to referral All out of hospital basic radiology benefits are only available to registered beneficiaries on referral by Prime Cure Medi Centres, Prime Cure appointed Network Doctors or a registered beneficiaries attending Specialist Practitioner. No out of hospital radiology benefits are afforded to registered beneficiaries who do not make use of Prime Cure Medi Centres, Prime Cure appointed Network Doctors or their attending Specialist Practitioner to obtain these benefits. 10

11 5A) RADIOLOGY SPECIALISED OUT OF HOSPITAL MRI s, CAT Scans, Angiography etc. R per registered family, per benefit year Any Service Provider, subject to referral and pre-authorisation by the Society All out of hospital Specialised Radiology, includes, but is not necessarily limited to - MRI s, CAT Scans and Angiography. Out of hospital Specialised Radiology benefits are only afforded to registered beneficiaries if they are referred for Specialist Radiology by their attending Prime Cure Medi Centre, Prime Cure appointed Network Doctor or attending Specialist Practitioner. Prior authorisation is required from the Society before members may make use of this benefit. 6) PATHOLOGY OUT OF HOSPITAL Blood & Urine Investigations R per registered family, per benefit year Any Service Provider, subject to referral All out of hospital Pathology benefits are only available to registered beneficiaries via Prime Cure Medi Centres, Prime Cure appointed Network Doctors or their attending Specialist Practitioner. No out of hospital pathology costs are paid for by Furnmed unless Prime Cure Medi Centres, Prime Cure appointed Network Doctors or an attending Specialist Practitioner has been utilised to obtain these benefits. 7) PRIVATE HOSPITALS, STATE HOSPITALS, DAY CARE CLINICS AND UNATTACHED OPERATING THEATRES In-patient Services for Ward Fees, Theatre Fees, Apperatus, Medication, Materials, Pathology, Radiology, General Practitioners and Specialist Practitioners Fees s s 100% of Agreed Tariffs of Service Provider R per incident, per registered beneficiary and R per benefit year, per registered family Nine (9) months of paid contributions for in-patient maternity benefits Any Service Provider A maximum of 100% of agreed tariffs of Service Providers for all in-patient hospitalisation benefits. Planned in-patient hospitalisation benefits are only afforded to registered beneficiaries if they have been referred for in-patient treatment by a Prime Cure Medi Centre, prime Cure appointed Network Doctor or their attending Specialist Practitioner. Pre-authorisation must be obtained from the Society for all planned hospitalisation or in-patient treatment. In cases of emergency/trauma admissions, the Society must be notified within 24 hours of the admission of a registered beneficiary. NB: The Society will only authorise in-patient treatment which is provided for in terms of its rules and up to incident limits and benefit year limits. The Society may determine that any benefits for in-patient hospitalisation or in-patient treatment of registered beneficiaries be at State or Provincial Hospitals/facilities only. 11

12 8) ALTERNATIVES TO HOSPITALISATION Frail Care, Step Down Nursing Facilities, Private Nursing and Hospice R1 000 per registered family, per benefit year Any Service Provider, subject to referral and pre-authorisation by the Society Pre-authorisation must be obtained from the Society before any of these benefits are utilised by registered beneficiaries. Benefits are only afforded to registered beneficiaries if they have been referred to these Service Providers and if acceptable written motivation for the use of these services has been obtained from the patient s attending Medical Practitioner and this written motivation has been submitted to the Society and the Society has authorised the use of these benefits. 9) AMBULANCE & EMERGENCY Unlimited Netcare 911 NB: The use of Netcare 911 s Ambulance Services is limited to urgent, essential Emergency Medical assistance and/or urgent, essential Emergency Medical transport only. No Ambulance and Emergency Medical Assistance Services costs are paid for by the Society unless Netcare 911 is utilised by registered beneficiaries for these benefits. 10) DENTISTRY Conservative Dentistry Unlimited Prime Cure Medi Centres or Prime Cure appointed Network Dentists Conservative dentistry includes consultations, examinations, amalgam fillings, extractions, flouride treatment, cleaning, treatment of pain and sepsis and oral hygiene instruction. No conservative dentistry benefits are afforded to registered beneficiaries for whatever reason who do not make use of Prime Cure Medi Centres or Prime Cure appointed Network Dentists for these benefits. 10A) DENTISTRY Specialised Dentistry R per registered family, per benefit year Prime Cure Medi Centres or Prime Cure appointed Network Dentists 12

13 Specialised dentistry includes - all dental treatment which is not considered to be conservative dentistry, including, but not necessarily limited to, root canal treatment, crowns and bridges, but excluding orthodontics. No specialised dentistry benefits are afforded to registered beneficiaries by the Society for whatever reason if they do not make use of Prime Cure Medi Centres or Prime Cure appointed Network Dentists for these benefits. 10B) DENTISTRY Dentures 1 set of plastic dentures per registered family once every 2 years commencing from the date that the first set of dentures is obtained. Prime Cure Medi Centres or Prime Cure appointed Network Dentists Dentures must be obtained from Prime Cure Medi Centres or Prime Cure appointed Network Dentists. Dentures obtained elsewhere will not be paid for by the Society and will be for the member s own account. 10C) DENTISTRY Oral Surgery R per registered family, per benefit year Any Service Provider, subject to referral and pre-authorisation by the Society Pre-authorisation must be obtained from the Society before this benefit is utilised by registered beneficiairies. This benefit is only afforded to registered beneficiaries if acceptable written motivation from the patient s attending Prime Cure Medi Centre, Prime Cure appointed Network dentist or attending Specialist Practitioner has been submitted to the Society and the Society has authorised the necessary treatment. 11) OPTICAL Eye Tests 1 eye test per beneficiary per benefit year Prime Cure Medi Centres or Prime Cure appointed Network Optometrists All eye tests must be done by Prime Cure Medi Centres or Prime Cure appointed Network Optometrists. No eye test benefits are afforded to registered beneficiaries by the Society for whatever reason, if they do not make use of Prime Cure Medi Centres or Prime Cure appointed Network Optometrists for this benefit. 13

14 11A) OPTICAL Spectacle Frames 1 set of spectacle frames per beneficiary once every 24 months commencing from the date the beneficiary obtains first set of frames Prime Cure Medi Centres or Prime Cure appointed Network Optometrists A standard range of frames is available to members and the supply of non-standard frames shall be for the member s own account. No spectacle frame benefits are afforded to registered beneficiaries by the Society for whatever reason, if they are not obtained from Prime Cure Medi Centres or Prime Cure appointed Network Optometrists. 11B) OPTICAL Spectacle Lenses 1 pair of clear single vision or bifocal lenses per beneficiary once every 24 months commencing from the date the beneficiary obtains first pair of lenses Prime Cure Medi Centres or Prime Cure appointed Network Optometrists No spectacle lens benefits are afforded to registered beneficiaries by the Society for whatever reason, if they are not obtained from Prime Cure Medi Centres or Prime Cure appointed Network Optometrists. NB: The supply of multi-focal or prescription lenses and the tinting of lenses shall be for the member s own account. 11C) OPTICAL Optical Surgery R per registered family, per benefit year Any Service Provider, subject to referral and pre-authorisation by the Society Pre-authorisation must be obtained from the Society before any of these benefits are utilised by registered beneficiaries. Benefits are only afforded to registered beneficiaries if acceptable written motivation from the patient s attending Prime Cure Medi Centre, Prime Cure appointed Network Optometrist or attending Specialist Practitioner has been submitted to the Society and the Society has authorised the necessary treatment. 14

15 12) REMEDIAL THERAPIES OUT OF HOSPITAL Physiotherapy, Biokinetics, Hearing Aid Acoustician, Podiatry, Psychology, Occupational Therapy, Speech Therapy, Orthoptic Treatment, Social Worker R per registered family, per benefit year Any Service Provider, subject to referral A maximum of 100% of NHRPL Scale of Benefit costs for consultations, examinations and treatment rendered to registered beneficiaries for remedial therapies. No costs for remedial therapy treatment will be paid for by the Society unless registered beneficiaries are referred to these suppliers by their attending Prime Cure Medi Centre, Prime Cure appointed Network Doctor or Specialist Practitioner. 13) SPECIALISED TREATMENT Chemotherapy, Radiotherapy, Dialysis, Blood Transfusions and Organ transplants (including anti rejection medication) Subject to annual in-patient hospitalisation benefits Any Service Provider, subject to referral and pre-authorisation by the Society Pre-authorisation must be obtained from the Society before any of these benefits are utilised by registered beneficiaries. Benefits are only afforded to registered beneficiaries if acceptable written motivation from the patient s attending Specialist Practitioner has been submitted to the Society and the Society has authorised the necessary treatment.. The Society may determine that these benefits only be afforded to members or their registered dependants at State Hospitals/Clinics/Facilities. 14) PROSTHESIS External Prosthesis R per registered family per benefit year Any Service Provider, subject to referral and pre-authorisation by the Society Pre-authorisation must be obtained from the Society before this benefit is utilised by registered beneficiaries. Benefits are only afforded to registered beneficiaries if acceptable written motivation from the patient s Prime Cure Medi Centre, Prime Cure appointed Network Doctor or attending Specialist Practitioner has been submitted to the Society and the Society has authorised the necessary supply or repair of external prosthesis. 15

16 15) APPLICANCES & ORTHOPEDIC SUPPLIES Nebulisers, Crutches, Braces, Stocking, Oxygen, etc R per registered family per benefit year Any Service Provider, subject to referral and pre-authorisation by the Society No costs for appliances or orthopedic supplies will be paid for by the Society if registered beneficiaries have not obtained written prescriptions for these goods from their attending Prime Cure Medi Centre, Prime Cure appointed Network Doctor or attending Specialist Practitioner. DEFINITIONS : or s: : : Co-payment or Levies: The maximum tariff the Society will pay for services, treatment, medication or goods supplied to a member or a member s registered dependants. The maximum amount which the Society will pay for services, treatment medication or goods supplied to a member or a member s registered dependants. The minimum period for which contributions must be paid to the Society before a registered beneficiary qualifies for benefits. The Healthcare Service Provider which must be used by a member or the member s registered dependants in order to qualify for benefits from the Society. The amount which is to be paid by the member to a Healthcare Service Provider for medical services, treatment, medication or goods rendered to a member or his/her registered dependants. : The total cost of all healthcare services, treatment or goods supplied to a member or a member s registered dependant/s. : The maximum refund tariff or amount paid by the Society. These refund tariffs or amounts are determined, from time to time, by NHRPL (National Health Reference Price List) and are also known as medical aid rates. Service Provider: Hospitalisation per Incident Limit: The person/s or organisation/s who render healthcare services, treatment, medication or goods to a member or the member s registered dependants. The benefit limit afforded by the Society to registered beneficiaries for each occasion and period that necessitates in-patient treatment at a Hospital/Clinic, Day Care Clinic or unattached Operating theatre. 16

17 ANNEXURE C EXCLUDED BENEFITS Medical expenses incurred by members and their registered dependants in connection with any of the following shall not be accepted as a liability of the Society and are regarded as excluded benefits: Any illness or injury arising out of illegal conduct, disorderly behaviour, indulgence in alcohol or intoxicating substances, or the misuse of drugs or the like. Treatment for any form of substance abuse. Treatment for continued illness where a member or member s registered dependant/s refuse or fail to observe any reasonable instructions or recommendations made by the member s attending Medical Practitioner/s. Treatment for injuries or illness arising from any attempted suicide, self inflicted injury or illness. Accidental injury for which a third party is liable to pay for treatment or compensation or which is covered by insurance, excluding in-patient hospitalisation and emergency services costs. Any treatment which may be required as a result of assault. The Society will only consider the payment of benefits if an affidavit and a police report is submitted to the Society, which indicates that the member or member s registered dependant is not responsible in any way for the assault. Any out-patient medical expenses which arise as a result of a motor vehicle accident. The Society will consider assisting with medical expenses up to the member s allocated annual benefits (if applicable). Any assistance with medical expenses may be subject to written confirmation from an attorney who is attending to the motor vehicle accident claim on behalf of the member that should the motor vehicle accident claim be successful that the Society will be reimbursed for expenses actually paid by the Society. Treatment for injuries or occupational diseases contracted by a member whilst on duty, to the extent to which an employer is legally liable to provide for treatment or cover. Treatment for illness or injury whilst on police or military service. Operations and/or treatment of choice or of a cosmetic nature. The supply of unprescribed or over the counter medication and any other form of medication as may be determined by the Society s Trustees from time to time. The supply of anabolic steroids, food supplements and contraceptives. Any remedies, preparations, devices and appliances as may be determined by the Medical Committee from time to time. Contact lenses and contact lens solutions. 17

18 Mental ailments, (excluding conditions such as depression, anxiety, stress and sleeping disorders). Any treatment, medication or operation which in the opinion of the Medical Committee will involve the Society in an unreasonable expense. Accounts received for payment by the Society 4 (Four) months after the date on which the services or treatment were rendered or goods supplied to a member or a member s registered dependants. Payment for the treatment of any pre-conditioned or congenital ailments shall be at the sole discretion of the Society s Trustees. Any services rendered, goods supplied or treatment received prior to qualifying for benefits. Any services rendered, goods supplied or treatment received after member s specified annual benefit allocation has been exhausted. Any treatment for HIV or AIDS (Excluding opportunistic ailments). Maternity benefits except for female members and female spouses. 18