RULES OF HOSMED MEDICAL SCHEME EFFECTIVE 1 JANUARY 2015

Transcription

1 RULES OF HOSMED MEDICAL SCHEME EFFECTIVE 1 JANUARY 2015 Contents 1 NAME LEGAL PERSONA REGISTERED OFFICE DEFINITIONS MISSION AND BUSINESS OF THE SCHEME MEMBERSHIP REGISTRATION AND DE-REGISTRATION OF DEPENDANTS TERMS AND CONDITIONS APPLICABLE TO MEMBERSHIP MEMBERSHIP CARD AND CERTIFICATE OF MEMBERSHIP CHANGE OF ADDRESS OF MEMBER AND MEMBER STATUS SUPENSION AND TERMINATION OF MEMBERSHIP CONTRIBUTIONS LIABILITIES OF PARTICIPATING EMPLOYER AND ITS MEMBERS CLAIMS PROCEDURE BENEFITS PAYMENT OF ACCOUNTS OR STATEMENTS EX-GRATIA PAYMENTS GOVERNANCE DUTIES OF BOARD OF TRUSTEES POWERS OF THE BOARD OF TRUSTEES DISCRETIONARY POWER OF THE BOARD OF TRUSTEES DUTIES OF PRINCIPAL OFFICER AND EMPLOYEES INDEMNIFICATION AND FIDELITY GUARANTEE FINANCIAL YEAR OF THE SCHEME BANK ACCOUNT AUDITOR AND AUDIT COMMITTEE GENERAL MEETINGS COMPLAINTS AND DISPUTES DISSOLUTION OR TERMINATION AMALGAMATION AND TRANSFER OF BUSINESS RIGHT TO OBTAIN DOCUMENTS AND INSPECTION OF DOCUMENTS AMENDMENT OF RULES RULES SUBJECT TO ACT Amended Scheme Rules docx

2 ANNEXURE A: BENEFIT OPTIONS ANNEXURE B: CONTRIBUTIONS AND LATE JOINER PENALTIES ANNEXURE C: CHRONIC DISEASES LIST ANNEXURE D: EXCLUSIONS AND LIMITATIONS ANNEXURE E: PRESCRIBED MINIMUM BENEFITS 2

3 RULES OF HOSMED MEDICAL SCHEME 1 NAME 1.1 The name of the Scheme is HOSMED MEDICAL SCHEME, hereinafter referred to as the Scheme. 1.2 The abbreviated name is Hosmed. 2 LEGAL PERSONA The Scheme is a registered medical scheme in accordance with the provisions of the Medical Schemes Act, 1998 which is capable in its own name of suing and of being sued and of doing or causing to be done all such things as may be necessary for or incidental to the exercise of its powers or the performance of its functions in terms of the Act, the Regulations promulgated thereunder and these Rules. 3 REGISTERED OFFICE The registered office of the Scheme shall be situated at Number 8 Victoria Link, Route 21 Corporate Park, Nellmapius Rd, Centurion, Gauteng Province, The Board may, however, resolve to change such registered address, in accordance with these Rules, to any other location in the Republic of South Africa, should circumstances so dictate. 3

4 4 DEFINITIONS 4.1 In these Rules, a word or expression defined in the Act, bears the meaning thus assigned to it and, unless inconsistent with the context. 4.2 Any reference in these Rules to: (1) A clause is, subject to any contrary indication, a reference to a clause of these Rules; (2) law means any law including common law, statute, constitution, decree, judgment, treaty, regulation, directive, by-law, order or any other measure of any government, local government, statutory or regulatory body or court having the force of law; and (3) Person means any natural or juristic person, firm, company, corporation, government, state, agency or organ of a state, association, trust or partnership (whether or not having separate legal personality). 4.3 Where a word or expression is given a particular meaning, other parts of speech and grammatical forms of that word or expression have a corresponding meaning. 4.4 The headings do not govern or affect the interpretation of these Rules. 4.5 Unless the context indicates otherwise an expression which denotes any gender includes both the others; the singular includes the plural, and the plural includes the singular. 4.6 The words including and in particular are without limitation. 4

5 4.7 The rule of interpretation that, in the event of ambiguity, the instrument must be interpreted against the party responsible for the drafting of the instrument does not have application. 4.8 The termination of these Rules does not affect those of its provisions which expressly provide that they will operate after termination, or which must continue to have effect after termination, or which must by implication continue to have effect after termination. 4.9 The following expressions have the following meanings: (1) Act The Medical Schemes Act, 1998 (Act No 131 of 1998) and the Regulations promulgated thereunder; (2) Administrator Any person who has been accredited by the Council in terms of the Act, and shall, where the obligation has been placed on a medical scheme, also mean a medical scheme; (3) Admission Date The date on which a person is admitted as a Member, or in respect of a Dependant the date on which such Dependant is admitted, or, in the case of an employer, the date on which such employer is admitted to participate in the Scheme in terms of these Rules; (4) Adult Dependant a person including a Spouse or Partner of a Member who is in fact wholly or partly dependent on a Member for financial support and who is 5

6 registered, in terms of these Rules, as an Adult Dependant including, but not limited to: (a) a divorced Spouse of a Member; (b) a relative, whether by affinity or consanguinity of a Member; (c) a Spouse of a Member under a customary union or under a union recognised as a marriage under the customs of any religion; (d) a person with whom a Member enjoys a relationship similar to the relationship of a legally married Spouse; (e) a child of a Member who meets the criteria of qualifying as a Child Dependant and is a Spouse in a customary or civil marriage; (f) any natural person who meets the criteria for qualifying as a Child Dependant of a Member and who receives in any calendar year, or on a continuing basis, an annual income of more than the maximum Social Pension prescribed in respect of that person in the year in question. (5) Annual Limit the Maximum Benefits to which a Member and his or her registered Dependants are entitled in terms of these Rules, and shall be calculated annually to coincide with the Financial Year of the Scheme; (6) Approval Approval of the Board or its authorised representatives; (7) Auditor 6

7 the auditor appointed by the Scheme, from time to time, to perform specific functions, including those prescribed in the Act and who is registered in terms of the Auditing Profession Act, 2005 (Act No 26 of 2005); (8) Authorisation Authorization prior to admission to a hospital or a day clinic or such other specific services or procedures as stipulated in a Benefit Option; (9) Beneficiary A Member or a Dependant duly registered as such in terms of the Rules; (10) Benefits Subject to the restrictions imposed by these Rules, the benefits to which a Beneficiary is entitled as set out in Rule 15 and in accordance with the Benefit Option in which the Member participates as provided for in Annexure B; (11) Benefit Options The benefit option which is applicable to a Beneficiary and which is approved by the Registrar from time to time, which approved benefit option and corresponding Contributions are attached as Annexure A. (12) Board The board of Trustees duly elected or appointed in accordance with the Act and constituted to manage the Scheme in accordance with the Rules and applicable legislation; 7

8 (13) Claim the amount which a Member seeks from the Scheme in respect of expenditure incurred by him or her in connection with Benefits in respect of which he or she and/or his or her Dependants are entitled to in terms of Rule 15 and the Benefit Option as recorded in Annexure A; (14) Chairperson The Chairperson of the Board elected in terms of Rule 18.7(1) (15) Child Dependant A person who is under the age of twenty one (21) years and who for the purposes of these Rules satisfies one of the following categories: (a) A natural child of a Member or of a Member s Spouse; (b) An adopted child of, or a child in the process of being adopted by a Member or a Member s Spouse, where the child is not the biological child of either of them; (c) A stepchild of a Member or of a Member s Spouse who is not the child of either of them; (d) A foster child of a Member or of a Member s Spouse; and (e) a child, other than any of the children specified in Rules4.9(15)(a) to 4.9(15)(d) above, to whom a Member is liable for family care and support, and in respect of whom the Member is able to provide an affidavit, attested to by the Member, which records the basis and extent of such liability upon which the application for the 8

9 person to be registered as a Dependant, i.e. a Child Dependant, is made; (f) A niece or nephew of a Member or of a Member s Spouse provided that such person is financially dependent on the Member or his or her Spouse; (g) A sibling of a Member or of a Member s Spouse provided that such a sibling is financially dependent on the Member or his or her Spouse; (h) A grandchild, great-grandchild and so forth of a Member or of a Member s Spouse who is Financially Dependent on the Member or his or her Spouse; any Dependent below twenty six (26) years of age, for the duration of any course for which that Dependant is registered as a bona fide student at an educational institution recognised as such by the Board, who is not receiving in any calendar year, or on a continuing basis, during the period of study an annual income of more than the Social Pension prescribed in respect of that person in the year in question; provided in all cases detailed above that a person. whose potential or actual eligibility as a Child Dependant is derived from his or her relationship to a former spouse of a Member, shall not be entitled to continue as a Dependant with immediate effect from the time that the relationship between the Member and his or her Spouse (whether matrimonial, contractual or court-ordered) formally terminates, unless the Board determines otherwise on good cause shown and for the period and subject to such conditions as it may impose from time to time; 9

10 (16) Chronic Diseases List (CDL) A list of chronic conditions where the Scheme will provide and pay for medication and the treatment of the chronic condition as contemplated in the Act; (17) Condition-specific Waiting Period a period during which a Beneficiary is not entitled to claim Benefits in respect of a condition for which medical advice, diagnosis, care or treatment was recommended or received as may be imposed by the Scheme in accordance with the Act and Rules; (18) Continuation Member (a) A Member who continues to be a Member in terms of Rule 6.3; or (b) A surviving Spouse and/or Dependant of a deceased Member who becomes a Member in terms of the Rules; (19) Contribution in relation to a Member, the amount, exclusive of interest, paid by or in respect of the Member and his or her registered Dependants as set out in Annexure B, if any, as membership fees and shall include Contributions to a personal Medical Savings Account, where applicable; (20) Council The Council for Medical Schemes as defined in the Act; 10

11 (21) Cost In relation to a Benefit, the net amount payable in respect of a relevant health service as contemplated by the Act and Rules; (22) Creditable Coverage in the case of a Late Joiner, any period of verifiable Medical Scheme membership of the applicant or his or her dependants, but excluding membership as a child dependant, terminating two years or more before the date of the latest application for membership; (23) Date of Service (a) in the case of a consultation, visit to or treatment by a Medical Practitioner, Dentist or Medical Auxiliary, the date on which each consultation, visit or treatment occurred whether it was for the same illness or not; (b) In the case of an operation, procedure or confinement, the date on which each operation, procedure or confinement occurred; (c) In the case of hospitalization, the date of each discharge from a hospital or a nursing home or the date on which membership is terminated, whichever date is the earlier; (d) In the case of any other Benefit, the date on which such Benefit was rendered or the Benefit or item was obtained. 11

12 (24) Dependant A person who qualifies as a Child Dependant or Adult Dependant in accordance with the provisions of the Rules and who is accepted and registered as a dependant which shall include - (a) A Member s Spouse or Partner who is not a member or a registered dependant of another Medical Scheme; (b) A Child Dependant referred to in Rule4.9(15) who is not a registered member or dependant of another Medical Scheme; (c) Any Adult Dependant as contemplated in Rule4.9(4) who is not a registered member or dependant of another Medical Scheme; and (d) Any other person who is recognized and accepted by the Board as a Dependant for purposes of these Rules; (SALGA) (25) Designated Service Providers a health care provider or a group of providers selected by the Scheme as the preferred providers to provide medical advice, diagnosis, care or treatment services to Beneficiaries in respect of one or more of the Prescribed Minimum Benefit Conditions in the manner set out in Annexure E; (26) Designated Service Provider Tariff 12

13 The fee determined in terms of an agreement between the Scheme and a service provider or a group of service providers in respect of the payment for the relevant health services. (27) Dispensing Fee The prescribed fee a pharmacist charges for dispensing medicine; (28) Domicilium Citandi et Executandi a Member s chosen physical address for purposes of these Rules at which correspondence, notices as well as legal process, or any other action arising therefrom, may be validly delivered and served on the Member; (29) Emergency Medical Condition The sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person s life in serious jeopardy; (30) Employee A person in the employment of a Participating Employer; (31) Employee of the Scheme The Principal Officer and any other person employed by the Scheme from time to time, including any consultant appointed by the Scheme and specifically determined by the Scheme to be an employee for purposes of these Rules; 13

14 (32) Ex gratia A payment towards relevant health care services which a concession is given at the discretion of the Board and not a right to which beneficiaries are entitled to. (33) Financial Year The financial year for the period of 1 January to 31 December of each year; (34) Financially Dependent in respect of a person means that the person does not earn more than the amount of the Social Pension from all sources of income (if any) recognised by the Board for this purpose and is dependent financially on the Member for access to medical benefits; (35) Formulary A list of medicines that the Scheme will pay for the treatment of acute and chronic conditions as per the Benefit Option the Member has selected; (36) General Meeting An annual general meeting or a special general meeting referred to in Rules 27.1 and 27.2 respectively; (37) General Waiting Period A period during which a Beneficiary is not entitled to claim any Benefits notwithstanding an obligation to make payment of Contributions; 14

15 (38) Good Standing A Member whose Contributions payable to the Scheme are not outstanding for more than two consecutive months; (39) Gross Income The total income received from a Participating Employer including all allowances or the cost to company expense or the total package as the case may be; (40) Income for the purposes of calculating Contributions in respect of a Benefit Option means any amount received by or accrued to or deemed to have been received by or accrued to a Member. which may include (a) average twelve (12) months earnings, commission or records arising from employment, which shall include self-employment and employment in the informal sector as well as arising from services rendered as an independent contractor; (b) Interest including capitalised interest from active and passive investments; (c) Income from leasing of assets (including property); (d) Any distributions received from a trust, discretionary or vested, where the Member is a beneficiary. 15

16 (41) Initial Board The board of trustees elected or/and appointed immediately after the Scheme is released from the curatorship which it was placed under from 2014; (42) Individual Member A Member who is self-employed or who works for an employer that is not a Participating Employer or a person who resigned from the employment of a Participating Employer, and continues membership of the Scheme; (43) Late Joiner an applicant or the Adult Dependant of an applicant who, at the date of application for membership or admission as a Dependant, as the case may be, is 35 years of age or older, but excludes any person who enjoyed coverage with one or more Medical Schemes as from a date preceding 1 April 2001, without a break in coverage exceeding three consecutive months since 1 April 2001; (44) Managed Health Care Organisation a person who has contracted with the Scheme, in terms of the Act, to provide managed healthcare services. The managed care provided by such entity shall be restricted to clinical and financial risk assessment and managed healthcare, with a view to facilitating appropriateness and costeffectiveness of relevant health services within the constraints of what is affordable, through the use of rules-based and clinical managementbased programmes; 16

17 (45) Maximum Benefits the total Benefits which may accrue to a Beneficiary in terms of these Rules for the Financial Year; (46) Medically Necessary the evaluation of healthcare services by a health professional or a multidisciplinary committee or panel appointment by the Scheme to determine if the healthcare services or level care is medically appropriate and necessary to meet the healthcare needs of the patient, consistent with the diagnosis or condition; rendered in a cost effective manner and type of setting appropriate to the supply of service required for the purposes other than comfort or convenience; and consistent in type, frequency and duration of Treatment with scientifically based guidelines of medical practice and of demonstrated medical value; (47) Medical Practitioner, Dentist or Medical Auxiliary a person registered as such in terms of the relevant legislation that governs that specific profession; (48) Medical Savings Account that part of a Member s Contribution which remains an asset, where applicable, of the Member, but is held by the Scheme for his/her and his/her Dependants exclusive benefit and use in accordance with the relevant Benefit Option and which funds are administered and regulated in terms of the Act and the Rules; (49) Medical Scheme 17

18 Any medical scheme registered in accordance with the Act; (50) Member any person who is registered as the principal member of the Scheme either through making an application and being accepted as the principal member of the Scheme or who may become the principal member of the Scheme in terms of Rule 6. (51) Negotiated Tariff a tariff negotiated and agreed ad hoc for services rendered between the Scheme and a healthcare service provider for services rendered by the relevant service provider to the Scheme or to Beneficiaries and which is different from the Scheme Tariff; (52) Non-Chronic Diseases List (non-cdl) condition Other chronic conditions which do not form part of the Chronic Diseases List and in which case payment shall depend on non-cdl Benefits specified per Benefit Option; (53) Participating Employer An employer who has contracted with the Scheme for purposes of admission of its Employees as Members; (54) Partner A person or persons with whom the Member has a sustained, committed, serious relationship akin to a marriage based on objective criteria of 18

19 mutual dependency and common household irrespective of the gender of either party; (55) Practice Code Number The number allotted to a supplier of healthcare services as a practice code number by the relevant registering authorities; (56) Pre-existing Condition a condition for which medical advice, diagnosis, care or treatment was recommended or received within the twelve-month period ending on the date on which an application for membership of the Scheme was made; (57) Prescribed Minimum Benefits the benefits contemplated in section 29(1)(o) of the Act, which, subject to the Act, consist of the provision of the diagnosis, treatment and care costs as contemplated in the Act, of (a) the diagnosis and treatment pairs listed in Annexure A of the Regulations, subject to any limitation specified therein; and (b) any Emergency Medical Condition; (58) Prescribed Minimum Benefit Condition a condition contemplated in the Diagnosis and Treatment Pairs or, where applicable, an Emergency Medical Condition, as contemplated in Annexure A of the Regulations and more fully set out in Annexure E; 19

20 (59) Principal Officer the chief executive officer of the Scheme appointed in terms of the Act and Rules; (60) Professional Person a person who performs a specific profession or who has specific professional skills for example in law, finance, human resources, and so forth; (61) Proxy a process whereby a Member who is in Good Standing and is unable to attend a General Meeting, nominates on the prescribed proxy form and in accordance with the Rules, another Member who will be present at the General Meeting to act on his or her behalf at such General Meeting; (62) Regulations the regulations being in force from time to time, and issued in accordance with the Act; (63) Scheme Tariff the tariff determined or adopted by the Board in respect of the payment for healthcare services rendered to Beneficiaries by service providers who are not subject to a DSP Tariff, as contemplated in Rule 15.11; (64) Single Exit Price legislative requirements by the Department of Health providing that medicine manufacturers may only sell their products at one price to all 20

21 their customers, regardless of the nature of the order size and consumption levels and that each and every product and its variants that exit the factory must have one single price; (65) Social Pension the appropriate maximum basic social pension prescribed by the Social Assistance Act, 1993 (Act No 13 of 2004); (66) Spouse the person or persons to whom the Member is married in terms of any law or custom; (67) Supplementary Services services rendered by all therapists including physiotherapists, masseurs, chiropractors, orthopedists, audiologists, hearing and acousticians, occupational therapists, podiatrists, chiropodists, dieticians, speech therapists, bio kinetics, private nurses, psychiatrists, psychologists and social workers as determined in these Rules; (68) the Registrar the Registrar of Medical Schemes appointed in terms of section 18 of the Act; (69) the Rules these rules of the Scheme which shall include the annexures to the Rules and any other provisions relating to the Benefits which may be granted and the Contributions which may become payable as amended from time to time; 21

22 (70) Trustee a trustee, appointed or elected as such in accordance with the provisions of Rule 18, in office from time to time; (71) Vice-Chairperson the vice-chairperson of the Board elected in terms of Rule18.1 (7). 5 MISSION AND BUSINESS OF THE SCHEME 5.1 Mission The mission of the Scheme is to operate a non-profit mutual Medical Scheme in terms of the Act in a financially responsible manner and apply the principles of good governance for the defrayal of its Member s healthcare expenses by means of- (1) the operation and administration of one or more benefit option(s); (2) the optimal appropriation of Contributions and other income; (3) the rendering and/or making provision for cost effective healthcare services; and (4) growing the Scheme to be a major role player in the industry. 5.2 Business The business of the Scheme is to undertake, within its financial means and subject to the provisions of the Act and these Rules, 22

23 (1) liability in respect of health and health-related expenses in respect of its Members and their Dependants in return for a stated Contribution or premium; (2) to make provision for the obtaining of relevant health services; (3) to grant assistance in defraying expenditure incurred in connection with the rendering of relevant health service; and/or (4) to render a relevant health service either by the Scheme itself, or by any supplier or group of suppliers of a relevant health service or by any person in association with, or in terms of an agreement with the Scheme. 6 MEMBERSHIP 6.1 Eligibility Subject to Rule 8, membership is open to any person or group of persons who are ordinarily resident within the Republic of South Africa, and shall be compulsory in respect of an Employee, who in terms of his or her conditions of employment, is required to become a Member. 6.2 Individual Members Any other person who is neither an Employee nor a Continuation Member of a Participating Employer may apply to become a Member. 6.3 Continuation Members (1) A Member shall retain his or her membership of the Scheme, subject to the Rules, as a Continuation Member with his or her registered Dependants, if any, in the event of his or her retiring from the services of 23

24 his or her employer, or his or her employment being terminated by his or her employer on account of age, ill-health or other disability. (2) A Continuation Member shall also include - (a) a Dependant who becomes a Member in terms of Rule 6.4; (b) a Member who resigns from the service of a Participating Employer but, subject to the Rules, opts to remain a Member. (3) The Member must inform the Scheme of his or her change of status. (4) The Scheme shall inform the Member, or the Dependant as the case may be, of his or her right to continue his or her membership and of the Contribution payable from the date of retirement or termination of his or her employment or his or her becoming a Member in terms of Rules 6.3(1), 6.3(2) or 6.4. Unless such Member informs the Scheme in writing of his or her desire to terminate his or her membership, he or she shall continue to be a Member. 6.4 Dependent of deceased Members (1) The Dependants of a deceased Member who are registered with the Scheme as Dependants at the time of such Member s death shall be entitled to retain membership of the Scheme as Members without any new restrictions limitations or waiting periods. (2) The Scheme shall inform such Dependants of their right to membership and of the amended Contributions payable in respect of their continued participation. Unless such a person informs the Scheme in writing of his or her intention not to become a Member, he or she shall be admitted as 24

25 a Member of the Scheme with effect from the first day of the month following the Member s death and be bound by the Rules. (3) Such a Member s membership shall terminate if he or she becomes a member or dependent of another Medical Scheme. (4) If a Member dies and such Member has Child Dependants, his or her surviving registered Spouse, shall be deemed to be a Member of the Scheme and the Child Dependants associated with such Spouse, registered at the time of the Member s death, shall be Dependants of the surviving Spouse until participation in the Scheme is terminated in accordance with the Act or Rules; (5) Where a Dependant(s) of a Member has/have been orphaned the eldest child shall be deemed to be the Member notwithstanding his or her age, and any younger siblings that are Child Dependant(s) shall be the Dependants of such eldest child. Unless the guardian of such eldest child informs the Scheme in writing of his or her intention that such child not becomes a Member. 7 REGISTRATION AND DE-REGISTRATION OF DEPENDANTS 7.1 Registration of Dependants (1) A Member may apply for the registration of his or her Dependants at the time that he or she applies for membership in terms of Rule8. (2) A Member must apply to register a newborn or newly adopted child as a Dependant within 60 days of the date of birth or adoption of the child for such a child to be registered by the Scheme as a Dependant. The Contributions in respect of such a child shall, after registration, be due as 25

26 from the first day of the month following the month of birth or adoption and Benefits will accrue as from the date of birth or adoption. (3) If a Member who marries subsequent to joining the Scheme applies within 60 days of the date of such marriage to register his or her Spouse as a Dependant, his or her Spouse shall thereupon be registered by the Scheme as a Dependent if he or she qualifies under the Rules. Increased Contributions shall then be due as from the first day of the month following the month of marriage and Benefits will accrue as from the date of registration of the marriage subject to the Act and Rules. (4) In the event of any person becoming eligible for registration as a Dependant other than the circumstances as set out in Rules 7.1(2) and7.1(3) the Member may apply to the Board for the registration of such a person as a Dependant whereupon the provisions of Rule 8 shall apply where relevant and appropriate. (5) In the event of a Member not applying within 60 days to register a Dependant, the Member must obtain the Board s Approval for such registration and a minimum of a three month waiting period shall apply in the case of the Dependant who has then been registered on Approval of the Board. 7.2 De-registration of Dependants (1) A Member shall inform the Scheme within 30 days of the occurrence of any event which results in any one of his or her Dependants no longer satisfying the conditions in the Rules and Act terms of which he or she may be a Dependant. 26

27 (2) A Member who fails to inform the Scheme of the change of status of his or her Dependant shall not be entitled to a refund of Contributions. (3) When a Dependant ceases to be eligible to be a Dependant, as contemplated in the Rules, he or she shall no longer be deemed, as from the date of such person ceasing to be eligible, to be registered as such for the purpose of these Rules or be entitled to receive any Benefits, regardless of whether notice has been given or received in terms of these Rules or otherwise. The Scheme may claim re-imbursement from the Member for Benefits paid on behalf of such Dependant and costs incurred after he or she ceased to be a Dependant in terms of these Rules. (4) The qualifying status of a Dependant who is deemed to be a Child Dependant in terms of the Rules shall be reassessed by the Scheme from time to time. If, at any time, such Dependant is found to no longer meet the qualifying criteria to be deemed a Child Dependant contemplated by the Rules, the Scheme shall, subject to such Dependant meeting the qualifying criteria to be regarded as an Adult Dependant, change such registered Dependant s status from that of a Child Dependant to that of an Adult Dependant, unless it is found that such Dependant is no longer an eligible Dependant, in which case the Scheme may at its discretion elect to proceed in terms of Rule 7.2(4). (5) Should a Member cease to be a Member for any reason other than his or her death, then such a Member s Dependants shall automatically cease to be Beneficiaries with effect from the date on which the Member ceased to be a Member. 27

28 8 TERMS AND CONDITIONS APPLICABLE TO MEMBERSHIP 8.1 Child A minor may become a Member with the consent of his or her parent or guardian. 8.2 Membership of one Scheme only (1) No person shall: (a) be a member of more than one Medical Scheme; (b) be admitted as a dependent of: (i) (ii) of more than one member of a particular Medical Scheme; or of members of different Medical Schemes; or (c) claim or accept benefits in respect of himself or herself or any of his dependants from any Medical Scheme in relation to which he is not a member or dependant. (2) Should it be established that a Member or a Dependant is a beneficiary of another Medical Scheme his or her Benefits will be suspended pending an investigation. 8.3 Application form and information required (1) An applicant shall, prior to admission, complete and submit the application form as prescribed by the Board, together with satisfactory evidence in respect of himself or herself and his or her dependants, age, Income, state of health and of any prior membership or admission as a dependant or a member of any other Medical Scheme. 28

29 (2) The Scheme may require an applicant to provide the Scheme with a medical report in relation to any proposed participant in respect of a Preexisting Condition. Proof of prior membership of a Medical Scheme may also be required. The costs will be paid by the Scheme at Scheme Tariff or DSP Tariff, as the case may be. The Scheme may designate a service provider to conduct such tests or examinations. 8.4 Waiting periods (1) The Scheme may impose upon a person in respect of whom an application is made for membership or admission as a Dependant, and who was not a beneficiary of a Medical Scheme for a period of at least 90 days preceding the date of application - (a) a General Waiting Period of up to three months; or (b) a Condition-specific Waiting Period of up to 12 months. (2) The Scheme may impose upon any person in respect of whom an application is made for membership or admission as a Dependant, and who was previously a beneficiary of a Medical Scheme for a continuous period of up to 24 months, terminating less than 90 days immediately prior to the date of application (a) a Condition-specific Waiting Period of up to 12 months, except in respect of any treatment or diagnostic procedures covered within the Prescribed Minimum Benefits; or (b) in respect of any person contemplated in this sub-rule, where the previous Medical Scheme had imposed a general or condition- 29

30 specific waiting period, and such waiting period has not expired at the time of termination, a general or condition-specific Waiting Period for the unexpired duration of such waiting period imposed by the former Medical Scheme. (3) The Scheme may impose upon any person in respect of whom an application is made for membership or admission as a Dependant, and who was previously a beneficiary of a Medical Scheme for a continuous period of more than 24 months, terminating less than 90 days immediately prior to the date of application, a General Waiting Period of up to three months, except in respect of any treatment or diagnostic procedures covered within the Prescribed Minimum Benefits. (4) If the members of a Medical Scheme who are members of that Medical Scheme by virtue of their employment by a particular employer, terminate their membership of that Medical Scheme with the object of obtaining membership of the Scheme, the Board will admit as a Member, without a waiting period, any member of such first-mentioned Medical Scheme to the Scheme and admit any person who has been a registered dependant of such a Member as a Dependant. (5) No waiting periods will be imposed on a person in respect of whom application is made for membership or admission as a Dependant and who was previously a beneficiary of a Medical Scheme, terminating less than 90 days immediately prior to the date of application, where the transfer of membership is required as a result of: (a) change of employment; or 30

31 (b) an employer changing or terminating the medical scheme of its employees, in which case such transfer shall occur at the beginning of the Financial Year, or reasonable notice must have been furnished to the Scheme for such transfer to occur at the beginning of the Financial Year; (6) in the cases referred to in Rules(2) and8.4(3) where the former Medical Scheme had imposed a general or condition-specific waiting period in respect of the persons referred to in these Rules, and such waiting period had not expired at the time of the said persons becoming Members or Dependants, the Scheme may impose a waiting period for the unexpired duration of a waiting period imposed by the former Medical Scheme. (7) No waiting period may be imposed on a Beneficiary who changes from one Benefit Option to another within the Scheme unless that Beneficiary is subject to a waiting period on his or her current Benefit Option in which case the remaining waiting period may be applied; (8) No waiting period may be imposed on a Child Dependant born during the period of membership. 8.5 Payment of Contributions and accrual of Benefits Subject to Rules 7.1(2) and 7.1(3)Contributions become due in respect of and Benefits accrue to Members and their Dependants on the first day of the month following acceptance of their applications for memberships. 31

32 8.6 Re-instatement of membership (1) In the event of a Member s membership having been terminated in terms of Rule11.7, the Member may apply to be re-instated after submitting proof that the relevant contravention of the Rules has been rectified. (2) The Scheme shall, after it is satisfied with the representations of the Member, re-instate membership of that Member. (3) Where a Member has defrauded the Scheme his or her membership shall be re-instated upon satisfactory proof that full rehabilitation has been achieved. 8.7 Dependants in same Benefit Option as Member The Dependants of a Member must participate in the same Benefit Option as the Member, provided that: (1) If the Scheme excluded the Member from a Benefit in respect of a particular illness, disorder or disability which existed at the time of admission, or has limited such Benefit, such exclusion or limitation shall not extend to any Dependant; and (2) if the Scheme has excluded a Dependant from a Benefit in respect of a particular illness, disorder or disability which existed at the time of admission or has limited such Benefit, such exclusion or limitation shall not extend to the Member or any other Dependant. 8.8 Cession, transfer, pledge or hypothecate of claim or benefit A Beneficiary may not cede, transfer, pledge or hypothecate or make over to any third party any Claim, or part of a Claim or any right to a Benefit which he 32

33 or she may have against the Scheme. The Scheme may withhold, suspend or discontinue the payment of any Benefit or any right in respect of such Benefit under these Rules, if a Beneficiary attempts to assign, transfer, cede, pledge or hypothecate such Benefit. 9 MEMBERSHIP CARD AND CERTIFICATE OF MEMBERSHIP 9.1 Membership card (1) Every Member shall be furnished with a membership card containing such particulars as may be prescribed by the Act. The membership card must be exhibited to the supplier of a service on request. It remains the property of the Scheme and shall be returned to the Scheme on termination of membership or destroyed by the Member. (2) The utilisation of a membership card by any person other than the Member or his or her registered Dependants is not permitted and shall be construed as an abuse of the privileges of membership of the Scheme as contemplated in Rule (3) On termination of membership or on de-registration of a Dependant for reasons contemplated in these Rules, the Scheme must, within 30 days of such termination or at any time on request, furnish such person with a certificate of membership and cover, containing such particulars as may be prescribed by the Act. 9.2 Rules (1) Every Member shall, on admission to membership, be able to access the Scheme s website, the details of which will be communicated to the Member, to view these Rules and the benefit guide, which shall include 33

34 Contributions, Benefits, limitations and the Member s rights and obligations in accordance with the Benefit Option on which the Member is registered. (2) The Scheme shall, on written request by the Member, provide the Member with a copy of these Rules in the manner agreed upon with the Member. 9.3 Binding force of Rules (1) Members and any person who claims any Benefit under these Rules or whose Claim is derived from a person so claiming are bound by these Rules as amended from time to time. (2) Payment by a Member or his employer or by any third party of the Contribution, or a portion of the Contribution, to the Scheme on behalf of a Member shall constitute the Member s acknowledgement that he is bound by these Rules and by any amendment of the Rules which may occur from time to time. 10 CHANGE OF ADDRESS OF MEMBER AND MEMBER STATUS 10.1 A Member must nominate a Domicilium Citandi et Executandi. In the event that the Member fails to nominate a Domicilium Citandi et Executandi, the Member s postal address or residential address on his or her application form shall be deemed to be his or her Domicilium Citandi et Executandi A notice sent by prepaid registered post to the Member at his or her Domicilium Citandi et Executandi shall be deemed to have been received by the Member on the seventh (7 th ) day after the date of posting. 34

35 10.3 Notices may also be sent by the Scheme to a Member s nominated address, postal address or fax number at the Scheme s discretion or where specifically requested by the Member. If a notice is dispatched to a Member s fax number or address, such a notice shall be deemed to have reached the Member upon successful transmission thereof. If a notice is sent to a Member s postal address, it is deemed that the Member will have received it on the seventh (7 th ) day after the date of posting A Member must notify the Scheme within thirty (30) days of any change of any contact details, including his or her Domicilium Citandi et Executandi. The Scheme shall not be held liable if a Member s rights are prejudiced or forfeited as a result of the Member neglecting to comply with the requirements of this Rule. 11 SUPENSION AND TERMINATION OF MEMBERSHIP Membership of a Member terminates under the following circumstances: 11.1 Resignation from service of Participating Employer (1) A Member who resigns from the service of the Participating Employer shall, on the date of such resignation be eligible to continue as an Individual Member without re-applying or the imposition of any new restrictions that did not exist at the time of his or her resignation; provided that the Member informs the Scheme of such resignation. (2) A Member who, in terms of his or her conditions of employment is required to be a Member, may not terminate his or her membership while he or she remains an Employee of a Participating Employer without the prior written consent of such employer. 35

36 11.2 Voluntary termination of membership (1) Participating Employer A Participating Employer must terminate its participation with the Scheme by giving two months written notice which must be received by the Scheme not later than the 7 th day of the first month of the notice period in order to be effective whereafter all rights of the Members of that Participating Employer, and any Dependants of such Members, shall cease after the said two months. (2) Member (a) A Member, who is not required as a term and condition of employment to participate in the Scheme, may terminate his or her participation of the Scheme by giving 30 days written notice which must be received by the Scheme not later than the 7 th day of the month in order to be effective where after all rights of that Member and his or her Dependants shall cease after the said 30 days. (b) The Scheme may waive the notice period referred to in Rules 11.2(1) and 11.2(2) above in cases where proof has been submitted that membership of another Medical Scheme becomes compulsory for the Members as a result of a condition of employment Membership whilst abroad (1) A Member who proceeds on leave outside the Republic of South Africa or is required to temporarily leave the Republic of South Africa on official duty may either apply to have his or her membership suspended during 36

37 such period of absence, or may elect to continue to receive the Benefits in accordance with the Benefit Option of his or her choice: Provided that Contributions are paid by or on behalf of such a Member and the Benefits thus received shall not exceed the amount that would have applied had the Member received the Benefits in the Republic of South Africa. (2) Except with the approval of the Scheme, where a Member ceases to reside in the Republic of South Africa, his membership shall terminate. (3) Except with the approval of the Scheme, where a Dependant ceases to reside is the Republic of South Africa his or her right to receive Benefits will cease Death (1) The Membership of a Member shall terminate in the month of his or her death: Provided that the surviving Spouse and Dependants of a deceased Member may opt to become Members in terms of Rule6.4. (2) A Dependant s right to receive Benefits will cease on the date of death of such Dependant Cessation of Benefits The right to Benefits of the Member and of any Dependants of a Member whose membership has been terminated, shall cease on the last day of the month in which membership has been terminated Failure to pay amounts due to the Scheme (1) If a Member or an employer on behalf of a Member, as the case may be, fails to pay any amounts due to the Scheme or contravenes Rules

38 and 12.2, the Member or employer, as the case may be, will be informed in writing by registered mail or or fax that he or she is in default of the Rules. (2) The Member or the employer, as the case may be, must be allowed 14 days to pay the outstanding amounts, or to make written representations to the Principal Officer in respect of the default. (3) If payments are not brought up to date, or no representations are made, or the representations are rejected by the Principal Officer, the Scheme may - (a) pay to or on behalf of the Member any Benefits claimed less the relevant amount owed by or in respect of the Member to the Scheme; and/or (b) deduct from any moneys owing to the Member by the Scheme, any relevant outstanding amount; and/or (c) suspend all benefit payments which have accrued to such Member and his or her Dependants, irrespective of when the Claim for such Benefits arose; and/or (d) terminate the Member s membership and institute any action to recover any losses and outstanding amounts as well as all costs incurred Contravention of the Rules of the Scheme (1) The Rules of the Scheme are contravened when a Member or his or her Dependant 38

39 (a) contravenes any provision of these Rules or fails to comply therewith; (b) omits to inform the Scheme of any changes in his or her status, Dependants or Income; (c) makes or causes to be made any Claim for the payment of any benefit allegedly due in terms of the Rules, knowing such Claim to be false; or (d) knowingly makes or causes to be made a false statement or representation of any material fact or omits to inform the Scheme of any information that is required in terms of the Rules for use in determining any right to any benefit allegedly due in terms of the Rules of the Scheme or other material information; or (e) having a knowledge of any fact or the occurrence of any event affecting his or her right to receive any benefit in terms of the Rules, fails to disclose such fact or event to the Scheme with the intention to obtain a benefit to which he is not entitled or a larger benefit than that to which he is entitled; or (f) commits a fraudulent act; or (g) fails to repay any debt due to the Scheme. (2) The Scheme may, at its discretion, exclude from Benefits or suspend (pending an investigation) or terminate the membership of a Beneficiary whom the Board finds guilty of contravening Rule 11.7(1) above. In such an event the Member may be required by the Scheme to refund to the 39

40 Scheme any sum of money which, but for the Beneficiary s abuse of the Benefits or privileges of the Scheme, would not have been disbursed. (3) A Member shall inform the Scheme within thirty (30) days of the occurrence of any event which results in him or her, or any one of his or her Dependants, no longer satisfying the conditions in terms of which he or she may be a Member, Child Dependant or Adult Dependant. (4) Should a Member fail to inform the Scheme as contemplated in Rule11.7(3), then (upon the Scheme discovering that such Member or any of his or her Dependants is no longer eligible to be a Member, Child Dependant or Adult Dependant), all claims and other amounts paid by or due to the Scheme from the date of disqualification of any such Beneficiary shall be repaid by the Member to the Scheme. All Contributions received by the Scheme in respect of any such disqualified Beneficiary shall be refunded to the Member with effect from the first day of the month following the month in which any such Beneficiary ceased to qualify as such. Any amounts due to the Scheme by the Member as contemplated in these Rules may be retained by the Scheme from the total contribution required to be refunded to the Member and any remaining Contribution will then be refunded. Where the Contribution to be refunded is less than any amounts owed by the Member, the Scheme will, in compliance with applicable legislation, seek to recover such outstanding amounts from the Member. 40

41 12 CONTRIBUTIONS 12.1 Total monthly Contributions (1) The total monthly Contributions payable to the Scheme by a Member in respect of a Benefit Option including Contributions in respect of Dependants, are stipulated in Annexure B, from time to time. (2) Contributions payable by a Member, from time to time, will be determined using criteria such as the following: (a) The number of Adult Dependants including Spouse or Partner of the Member; (b) The number of Child Dependants of a Member; (c) Income as determined should the option provide for such; (d) Benefit Option selected including the application of network restrictions, if any; and (e) Existence of a Medical Savings Account. (3) It is the responsibility of the Member or of the Participating Employer, as the case may be, to notify the Scheme within 30 days of any change in the income of the Member that may necessitate a change in Contribution. (4) Premium penalties for persons joining late in life may be applied in accordance with the provisions of the Act Due date for Contributions (1) Contributions payable by Members of a Participating Employer shall be due monthly in arrears and be payable by not later than the third day of 41