ADMED - Frequently Asked Questions

Transcription

1 ADMED - Frequently Asked Questions 1. WHAT DOES ADMED COVER? 2. The shortfall, or gap, is defined as the amount by which the actual cost, not exceeding the Admed Tariff, less the actual amount payable by the medical scheme. 3. WHEN DOES ADMED APPLY AND WHEN DOES IT NOT APPLY? It applies only for claims incurred while you are Hospitalised (operation, accident, illness etc) and for certain procedures performed on an out-patient basis (day-to-day services) at a doctor s surgery like a gastroscopy, colonoscopy, removal of cataracts and certain biopsies. It does not apply for day to day services ie. Dentistry, Optometry, medication, GP or specialist visits etc. It does not cover the Hospital stay, materials and prosthesis (depending on product type). ADMED ADDITIONAL BENEFITS Frequently Asked Questions 1. WHAT IS THE SHORTFALL BENEFIT? Offers unlimited cover for in-hospital co-payments and deductibles subject to the Policy terms and conditions. This benefit includes co-payments of MRI/ CT and PET scans on an out-patient basis. ONCOLOGY BENEFIT 2. DOES THE BENEFIT ONLY APPLY TO THE ONCOLOGY CO-PAYMENT? This benefit only applies to the co-payment. The benefit will pay up to a maximum of 20% co-payment once the member s oncology benefit has been exhausted subject to the R per beneficiary per person per annum. SHOULD THE MEMBER BE REGISTERED ON THE ONCOLOGY PROGRAMME? Yes, the member has to be registered on the medical scheme s oncology programme. 3. DOES THE LUMP SUM CANCER BENEFIT COVER ALL TYPES OF CANCER Yes, Members will receive a once off benefit of R on first time diagnosis for all types of cancer during the insured period 4. WHAT IS THE SHORTFALL SUB-LIMIT BENEFIT Where an internal prosthesis was used and the Scheme s limit has been exhausted, Admed will pay the shortfall up to a limit of R per family per annum. 5. HOW MUCH DOES IT COST & IS THERE ANY AGE RESTRICTION UPON JOINING THE POLICY? Admed is a group rated policy. Therefore, a group rate will be applicable irrespective of the size of your family. There is no age restriction upon joining the policy. 6. WHO CAN JOIN ADMED? Any member who is registered as a principal member or a dependant on a medical aid scheme. WHAT PROOF OF MEMBERSHIP DO YOU RECEIVE AS A MEMBER?

2 All members who join Admed will receive a Membership Certificate (indicating a unique member number) and a Policy Document. 7. HOW AND WHEN DO MEMBERS CLAIM FROM ADMED? Members have 6 months from the date of admission to hospital or other qualifying event, to notify Guardrisk in writing, of the claim. Members are however encouraged to submit a claim as soon as possible after the event. Members can obtain claim forms directly from Guardrisk. 8. HOW IS THE BENEFIT PAID & TO WHOM IS IT PAID? Claim payments under the Admed insurance policy are deposited directly into the principal member s bank account. The benefit is paid directly to the principal member and the principal member is responsible for settling the accounts with the doctor. 9. HOW LONG DOES IT TAKE TO PAY A CLAIM? Approximately 7 working days, after receipt of all claim documentation, provided we have all the supporting documentation. 10. WHAT DOCUMENTS DO I NEED TO SUBMIT WHEN LODGING A CLAIM? Completed Admed claim form and all supporting documents e.g. hospital account, medical practitioner s accounts and medical aid statement. AdmedAdd + members should submit invoices/receipts when submitting a claim for the stated benefit portion. 11. CAN YOU STILL CLAIM IF YOU HAVE GIVEN NOTICE TO LEAVE THE ADMED POLICY? Yes, you are still covered until the last day of your notice period and given that your contributions are paid up. Claims after that date will not be processed. 12. WHAT DOES ADMED NOT COVER? Please refer to Policy document for list of exclusions. 13. WHAT ARE THE TYPES OF WAITING PERIODS THE POLICY CAN GIVE YOU? Waiting periods are applicable to Voluntary membership groups. birth related claims: 10 months from date of commencement first 6 months of cover: 0% benefit second 6 months of cover : 50% benefit for: Joint replacements (except as a result of an accident/injury occurring after joining) Arthroscopic procedures (except as a result of an accident/ injury occurring after joining) Spinal surgery including spinal fusion (except as a result of an accident/injury occurring after joining) Nasal surgery including sinus related (except as a result of an accident/injury occurring after joining) Cataract surgery Hysterectomy (except for cancer diagnosed after joining) Dentistry related claims (except reconstructive as a result of an accident/injury occurring after joining) All hernia repairs (except as a result of an accident/injury occurring after joining) and All cardiac related surgery and procedures (including angioplasty, cardiac catheterization etc.) diagnosed prior to date of joining. In conjunction with the above a 3 month general waiting period would be applied to all individual membership not linked to a group scheme. 14. WHAT DOES A WAITING PERIOD MEAN? Period during which a member has to pay his normal monthly contribution but is not entitled to claim benefits from the policy. Please refer to the Policy document for the list of waiting periods

3 15. WHO QUALIFIES AS A DEPENDANT? - A Child, including legally adopted child or stepchild of a Principal Insured Person and who is registered as their dependant on a medical aid scheme. - The Spouse, of a Principal Insured Person and who is registered as their dependant on a medical aid scheme. - A Parent or Sibling of a Principal Insured Person and who is registered as their dependant on a medical aid scheme. 16. CAN GUARDRISK TERMINATE MY ADMED MEMBERSHIP? Yes, on non-payment of premiums. 17. WHAT HAPPENS IF THE PRINCIPAL INSURED PASS AWAY BEFORE MY SPOUSE? Your spouse could still continue the cover should they elect to do so provided they inform the Administrator in writing within 60 days. ADMED ADMINISTRATION Frequently Asked Questions MUST I GIVE NOTICE TO THE POLICY ADMINISTRATOR IF I WANT TO TERMINATE MY ADMED MEMBERSHIP? Yes, we require a calendar month s written notice of your intention to leave the policy HOW IS THE PREMIUM COLLECTED? Through a debit order facility IS ADMED A REGISTERED POLICY? Admed is a registered short-term Insurance Health and Accident policy. WHICH INSURER UNDERWRITES THIS POLICY? The policy is underwritten by Guardrisk Insurance Company Limited, which is a wholly owned subsidiary of Alexander Forbes one of South Africa's leading financial service companies in South Africa. WILL I BE RQUIRED TO GO FOR A MEDICAL EXAMINATION TO QUALIFY FOR THE POLICY? There are no medicals required when applying for this policy and cover is immediately available. IS THE POLICY ONLY AVAILABLE OR LIMITED TO CERTAIN MEDICAL SCHEMES? No, the policy is available to any member belonging to a registered medical aid scheme. IS ADMED A CONTINUOUS POLICY OR DO I HAVE TO APPLY EVERY YEAR? Admed membership automatically rolls-over to the new policy period, unless the member elects not to continue with his/her membership. DOES THIS POLICY HAVE A SURRENDER VALUE? There is no savings or endowment portion and there is therefore no surrender value on the policy.

4 ADMED Frequently Asked Questions PERSONAL ACCIDENT SECTION Permanent Disability WHO CAN CLAIM UNDER THE PERSONAL ACCIDENT SECTION? The Personal Accident benefit is available to All insured members at no additional costs. WHAT IS DEFINED AS AN ACCIDENT? An Accident is ANY event that results in your body being unintentionally injured. Examples of Accidents can be as follows: Motor Vehicle Accidents (MVA s), Recreational Sports Injuries, Injuries on Duty, Injuries at Home, Snake, Dog and/or Spider Bites, Hi-Jacking and/or Assault WHAT DOES IT MEAN TO BE PERMANENTLY DISABLED? Permanent Disability, broadly speaking, means that your body has been altered / damaged following an Accident, to a severe enough degree that it will never recover 100%. Some examples of Permanent Disability can be as follows: o Paraplegia following a Motor Vehicle Accident here you would qualify for 100% of the Permanent Disability lump sum benefit o Loss of a whole finger following an attack by a dog here you would qualify for 15% of the Permanent Disability lump sum benefit But, not all cases can determine the level of Permanent Disability directly after an Accident. If we use the example of a serious multiple bone break in your leg, following a sporting Accident, the Insurers will require that on-going medical reports be supplied to them in order to plot your recovery progress during your months of therapy following a number of operations. If it is determined that you have a permanent degree of loss of movement following therapy, which will never return fully, the Insurer will still consider paying a portion of the Permanent Disability lump sum to you, as a result of the permanent (though not total) damage incurred to your leg. IS THERE A TIME PERIOD THAT CLAIMS NEED TO BE NOTIFIED IN? Yes, all claims need to be notified within 180 days following the date of the Accident. HOW LONG DOES IT TAKE BEFORE THE PERMANENT DISABILITY BENEFIT IS PAID? Insurers have up to 24 months to determine the level of Permanent Disability prior to releasing the lump sum benefit to the Insured Member. But, as mentioned above, this will be in severe cases where the level of disability cannot be determined directly after an Accident. Each case will be handled individually, but it is important to remember that the claim can only be assessed once ALL relevant documentation is received this will include a Medical Certificate (included in the Claim Form) which requests details of your injuries as well as recovery prognosis from a Medical Practitioner, ongoing medical reports (where required) as well as any other Medical motivation required, a copy of the Traffic Collision Report (in the event of a Motor Vehicle Accident), a copy of the Police Report (in the event of a criminal act e.g. a hijacking, assault etc.)

5 WHAT WILL THE PERSONAL ACCIDENT SECTION NOT COVER? The Insurers shall not be liable to pay any claim under this Section in respect of any Insured Person 1. while engaging in flying as pilot or member of the crew. This exception does not apply to Insured Persons engaging in ballooning, hang-gliding, paragliding and parachuting, provided that such activities are solely for social and/or pleasure purposes and not of a competitive nature or for reward 2. caused by the Insured Person's intentional self-injury 3. caused solely by an existing physical defect or other infirmity of the Insured Person 4. as a result of the influence of alcohol, drugs or narcotics upon the Insured Person unless administered by a member of the medical profession (other than himself) or unless prescribed by and taken in accordance with the instructions of a member of the medical profession (other than himself) 5. caused by the Insured Person's participation in any riot or civil commotion 6. arising from war, invasion, act of foreign enemy, hostilities (whether war be declared or not), civil war, rebellion, revolution, insurrection, military or usurped power 7. as a result of the Insured Person's deliberate exposure to exceptional danger (except in an attempt to save human life) or the Insured Person's own criminal act 8. while participating in sport as a professional player. 9. directly or indirectly caused by or contributed to by or arising from ionising radiations or contamination by radio-activity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel or from any nuclear weapons material. For the purpose of this exception only, combustion shall include any self-sustaining process of nuclear fission. BESIDES THE PERMANENT DISABILITY LUMP SUM BENEFIT, ARE THERE ADDITIONAL BENEFITS THAT FORM PART OF THE PERSONAL ACCIDENT SECTION? There absolutely are! The following Automatic Extensions will also be included in your Policy, again, at no additional cost to you. It is important to remember that these also apply in the event of an Accident: Emergency Transportation/Search and Rescue up to R25,000 Death Benefit - up to R Life Support Equipment up to R25,000 Trauma Counselling up to R750 per visit, with an annual limit of R25,000 Claims Preparation Costs up to R20,000 Mobility up to R25,000 Rehabilitation up to R25,000 RAF Medico Legal Costs up to R10,000 For additional information on Admed, an explanation of the Personal Accident Automatic Extensions as well as to access the Personal Accident Claims Guide, please visit our website, the details of which are : - Under Choose Your Interest, please select Admed. IF I AM INVOLVED IN AN ACCIDENT BUT AM NOT DISABLED, CAN I STILL CLAIM FROM THE AUTOMATIC EXTENSIONS? Yes you can. In the event of your Medical Scheme not covering the full cost of the Ambulance, you can submit a claim under the Emergency Transportation Automatic Extension, which will pay the balance of the account NOT covered by your Scheme, up to a maximum of R25,000. It is important to remember that you will need to attach your Medical Scheme statement which confirms the amount that has not been paid by your scheme. It is equally important to remember that only Ambulance costs as a result of an Accident will be covered under this benefit (any illness related transport costs will unfortunately not be covered under this section). ADMED - PERSONAL ACCIDENT AUTOMATIC EXTENSIONS

6 Please note the additional Automatic extensions that are also available when accessing the Accidental Bodily Injury section of your Admed Policy, where applicable: 1. EMERGENCY TRANSPORTATION / SEARCH AND RESCUE maximum of R25,000 The Insurers will pay costs and expenses necessarily incurred for: 1. emergency transportation 2. search and rescue, including freeing and bringing an Insured Person to a place of safety as a result of, or in order to prevent, accidental bodily injury to an Insured Person, provided that (a) Insurers will not be liable if an Insured Person is found in circumstances which are unlikely to result in accidental bodily injury (b) The maximum amount payable by Insurers will be R any one Insured Person for each and every claim. 2. LIFE SUPPORT EQUIPMENT maximum of R25,000 The Insurers will pay reasonable costs and expenses, incurred as a result of accidental bodily injury, in respect of hire costs for life support machinery, equipment or apparatus, provided that the Insurers liability is limited to R any one Insured Person for each and every claim. 3. TRAUMA COUNSELLING up to R750 per visit, with an annual limit of R25,000 If an Insured Person is subjected to an act of violence or a traumatic accident, Insurers will reimburse such person for counselling fees actually incurred by such person as a result of the act of violence or traumatic accident, provided that the maximum amount payable by Insurers will be R750 per visit and R per annum for each Insured Person act of violence shall mean an assault, robbery, rape, kidnapping or armed car hijack for the purposes of this extension only, Insured Person shall include immediate family members of such Insured Person the act of violence has been reported to the police and a case number obtained. This extension also covers any Insured Person who witnesses such an act of violence or traumatic event, provided that it arises in the course of the Insured Person s employment with the Insured. 4. CLAIMS PREPARATION COSTS maximum of R20,000 The insurance by this Policy extends to include costs reasonably incurred by the Insured in producing and certifying any particulars or details required by the Insurers to substantiate a claim, provided that the liability of the Insurers for such costs for any one Insured Person in respect of each and every claim shall not exceed the amount stated in the Schedule. 5. MOBILITY maximum of R25,000 When the Insurers have admitted a claim for Permanent Disability, if as a direct result of that disability the Insured Person is permanently dependent on a wheelchair for mobility, the Insurers will, in addition to any amount payable for Permanent Disability, pay for a self-propelled wheelchair the fitting of wheelchair loading equipment and alterations to the Insured Person's residence to facilitate the use of such wheelchair the modification of the controls to the Insured Person's motor vehicle provided that the liability of the Insurers for such costs in respect of each and every claim shall not exceed the amount stated in the Schedule for any one Insured Person. 6. REHABILITATION maximum of R25,000 If an Insured Person is permanently disabled to the extent that he is unable to follow his usual business or occupation but can be retrained to carry out another business or occupation, Insurers will, in addition to any Permanent Disability benefit agreed, pay 80% of the retraining costs, plus any costs incurred in adjusting

7 the Insured Person's workplace, provided that the maximum amount payable by Insurers will not exceed the amount stated in the Schedule for any one Insured Person. 7. RAF MEDICO LEGAL COSTS maximum of R10,000 The insurance by this Policy is extended to include costs reasonably incurred by the insured Person, following a motor vehicle accident, to undergo a medical legal examination to substantiate a Road Accident Fund claim, provided that the liability of the Insurers for such costs for any one Insured Person in respect of each and every claim shall not exceed the amount stated in the Schedule. This extension will only apply in cases where the Insurer expects the percentage of partial disability to exceed 30% and the Insurer must first approve the appointment of a medical legal examination.