AFRICAN UNITY HEALTH (AUH) GAP COVER - NEDGROUP

Transcription

1 AFRICAN UNITY HEALTH (AUH) GAP COVER - NEDGROUP WHAT IS GAP COVER? Gap cover is a short-term insurance product designed to assist you with covering the shortfalls that may arise during a hospital admission for a medical procedure due to the doctors and specialists charging a higher rate than what your medical scheme pays, or when you are required to pay a co-payment or upfront cost for a procedure. Although Gap cover does not cover out-of-hospital procedures, it does cover certain listed procedures performed on an out-patient basis. You must be a member of a registered South African medical scheme to qualify for Gap cover however the policy is not linked to your medical scheme. WHY DO I NEED GAP COVER? Your medical scheme may cover your medical procedures up surgeons and anaesthetists charge well above the medical than what the medical schemes cover. The tariff shortfall or Gap between what the service providers charge and the rate the scheme pays will be for your own pocket, unless you have an AUH Gap Cover Policy of course! You may also be required by the medical scheme to pay procedure or scan from your own pocket. The examples below are of recent claims paid by African Unity Health. H E A L T H please contact the Customer Care Centre: Tel: gapadmin@auhealth.co.za PROCEDURE SPECIALISTS CHARGED MEDICAL SCHEME PAID SHORTFALL/GAP PAID Caesarean section R Tonsillectomy R Knee replacement R R Natural childbirth R Coronary bypass Fractured Thumb repair R R R The average tariff shortfall/gap Cover claim in 2015 was R4 821 per event. WHO CAN JOIN, AND WHO IS COVERED? Any active employee or pensioner who is a member of the Nedgroup Medical Scheme can join and cover will be available for you, your spouse (or life partner) and all dependants registered on your medical scheme membership. WHAT DIFFERENT LEVELS OF COVER ARE AVAILABLE? NEDGROUP OPTION 1: R140 PER FAMILY PER MONTH Gap cover: Covers the tariff shortfalls on doctors and specialists accounts on authorised in-hospital procedures (includes a list of selected procedures done in doctors rooms) as a result of the medical practitioner charging more than the medical scheme reimbursement rate. scheme rate and includes in-hospital shortfalls for radiology, pathology, physiotherapy as well as shortfalls on procedures except for dental implants. Co-payment cover: Unlimited cover for the standard copayments or upfront deductibles imposed by your medical scheme on authorised in-hospital procedures and/or the necessity for kidney dialysis, MRI and CT scans done on an outpatient basis. (Any co-payments charged due to you not following your Medical Scheme rules in regards to the use of designated service providers will not be covered) Sub-limit cover: Cover for shortfalls on medical or surgical procedures or the shortfall on internal prosthesis above a sub-limitation in terms of the Medical Scheme rules. Emergency casualty cover: Covers the costs incurred in a hospital emergency unit in the event of a sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment, where failure to provide such treatment places the person s life or limb in serious jeopardy. Accidental Injury cover: On the death or permanent and total disablement of an insured person resulting from an Medical Scheme premium waiver: On the death or permanent and total disability of the principal member the medical scheme premium at the same level for a period of 6 months, limited to a maximum premium of Cancer cover: Call a Doctor Call a Nurse: ER24 medical personnel, including paramedics, nurses and doctors, will be available 24 hours a day to provide general medical information and advice via the Medical Information and Assistance Hotline. Administrator: African Unity Health (Pty) Ltd, an authorised Financial Services Provider (FSP 43066) Insurer: Constantia Insurance Company Limited, an authorised Financial Services Provider (FSP 31111) Broker: Towers Watson (Pty) Ltd, an authorised Financial Services Provider (FSP 2545)

2 NEDGROUP OPTION 2: R155 PER FAMILY PER MONTH additional cover for: Oncology Co-payment cover: The policy will cover the shortfalls on chemotherapy or radiotherapy, including biological cancer drugs, as a result of co-payments or deductibles imposed by your Medical Scheme once you you are the pilot or any form of motorised race or speed test Suicide, attempted suicide, or intentional self-injury. Emergency casualty services, other than in a hospital casualty ward or emergency casualty admissions paid from the risk portion of your medical scheme. Any pre-existing form of cancer will exclude members from WHAT ARE THE WAITING PERIODS? There are no waiting periods for employees who join the gap cover in the same month as they join the company medical scheme or during annual open window periods. Employees who join during the course of the year will have a 3 month period. Employees must remain on cover the entire year and may only terminate their cover on the annual renewal in December. WHAT ARE THE LIMITS IMPOSED ON MY COVER? The tariff shortfall or Gap on professional services will reimbursement rate. There is no overall limit on cover for tariff shortfalls. Unlimited cover for standard co-payments and deductibles. policy per annum. per policy per annum. policy per annum. The medical scheme premium waiver cover is limited to months. per event. WHAT ARE THE EXCLUSIONS? Co-payments as a result of not following the medical scheme rules in respect of network providers and preauthorisations or referrals. Admin fees, levies or doctors co-payments not related to the medial scheme. Ward fees and theatre fees are not covered. All cost related to dental implants. Depression, insanity, mental or mental stress-related conditions. You exceeding your overall annual limit on your medical scheme. Any procedure or code paid as an exception, or any code not paid or declined by your medical scheme. Contamination from nuclear weapons or nuclear material. Investigations, treatment or surgery for obesity or cosmetic surgery or infertility. Illness or injury as a direct result of the insured person millilitres of blood or the taking of any drug or narcotic unless prescribed by a registered doctor. Participation in active military duty, police duty, police reservist duty, civil commotion labour disturbances, riots or strikes or war. HOW DO I CLAIM? Gap cover does not form part of your medical scheme you must submit a separate claim to African Unity Health after your medical scheme has assessed your claims. It remains your responsibility to ensure you are aware of the medical scheme rules and potential shortfalls related to your procedure. You must submit your claim form with ALL the necessary documents (hospital account and relevant provider accounts, as well as a medical aid statement) after the Claims received after 6 (six) months will be rejected as stale. Claim forms are available from your HR department, your broker or the African Unity Health Customer Care Centre on Claims will not be paid to the service provider and it is in your best interest to settle the shortfall with the service provider as interest on overdue accounts is not covered. Payment will be made within 7 to 14 working days after all required documents have been received. IMPORTANT NOTES You are not allowed to upgrade or downgrade your cover during the course of the year, changes may only be made at renewal which is annually on 31 December. Employees must remain on cover until 31 December or on termination of employment. On termination of employment you may choose an individual Gap cover product and complete a continuation form if you want your cover to continue uninterrupted. If you do not submit a signed continuation form when you exit the employer, your cover will lapse automatically. It is your responsibility to ensure you are familiar with the selected option. Although African Unity Health will endeavour to collect premiums every month it remains your responsibility to ensure your premium is deducted from your salary every month. If no premium is received for 2 consecutive months your cover will lapse and waiting periods will be applied at re-instalment. No backdating of cover will be allowed. Your Gap Cover policy is not linked to your medical scheme and you need to cancel it separately with African Unity Health when you cancel your medical scheme membership. No premium will be refunded where you neglect to cancel your policy. Disclaimer: The above brochure is merely a summary of the will be available from the Administrator and is subject to the Administrator: African Unity Health (Pty) Ltd, an authorised Financial Services Provider (FSP 43066) Insurer: Constantia Insurance Company Limited, an authorised Financial Services Provider (FSP 31111) Broker: Towers Watson (Pty) Ltd, an authorised Financial Services Provider (FSP 2545)

3 AUH GAP NEDGROUP OPTION 1 MASTER POLICY NO: AUH NED1 ISSUED TO AFRICAN UNITY HEALTH (PTY) LTD

4 In consideration of and conditional upon the prior payment of the premium by or on behalf of the Insured and the receipt thereof by or on behalf of Constantia Insurance Company Limited, (the Company) before the inception date or renewal date (as the case may be) and subject to the terms exceptions conditions and provisions of the policy the Company agrees to pay the principal insured person for an insured incident occurring during the period of insurance up to the limit of indemnity stated for the insured person and the benefit as stated in each section of the Policy DEFINITIONS In this policy words importing the masculine gender shall be deemed to include the feminine gender and words importing the singular number shall be deemed to include the plural number and vice versa, and the following expressions shall have the following meanings: 1. Accident means bodily injury caused by violent accidental and external physical means 2. Biological Cancer Drug means a substance that is made from a living organism or its products and is used in the prevention, diagnosis, or treatment of cancer. For the purpose of this Policy Biological Drugs include antibodies, interleukins, and vaccines. 3. Eligible child means a child including a legally adopted child or stepchild who has not attained the age of twenty three (23) of a principal insured who is not already insured under this policy or any other insurance issued by the Company providing similar cover This age may be extended to 25 in respect of an unmarried child who is a full time student. There will be no age restriction for children who are either mentally or physically incapacitated from maintaining themselves, always provided that the children are wholly dependent on the Principal Member for support and maintenance. Once a child has become independent of the principle member for support and maintenance, dependency and therefore definition of a child cannot be revived at a later date unless that child is still under the age of twenty one (21). 4. Eligible member means a principal insured person who is in a category of paid up members as designated by the Insured and accepted by the Company as eligible for participation in the insurance provided by this policy and such other person as the Company may from time to time deem eligible. 5. Eligible spouse the spouse of the principal insured person who is not already insured under this section or any other policy issued by the Company providing similar cover Where a person shares an abode with a principal insured person and has done so for at least six (6) months and lives together in the manner of a legally married couple the person shall be regarded as a spouse. Should a principal insured person have more than one spouse who could qualify as an eligible spouse then any claim shall determine that that principal insured person has made an irrevocable nomination of one eligible spouse to whom the benefits shall apply 6. Eligible Extended family Dependant means any other adult dependant that is registered as an adult dependant of or alongside the Principal Insured Person. 7. Emergency means an admission to a hospital emergency unit following an event of a 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 8. Family means the principal insured person and such person s eligible spouse provided such spouse is an insured person but not a principal insured person and such person s eligible children provided they are insured persons

5 9. Hospital means any institution in the territory of RSA which in the opinion of the Company meets each of the following criteria: a. Has diagnostic and therapeutic facilities for surgical and medical diagnosis treatment and care of insured and sick persons by or under the supervision of a staff of medical practitioners b. Provides nursing service supervised by registered nurses or nurses with equivalent qualifications c. is not other than incidentally either a mental institution or a convalescent home d. is not a place of rest for the aged or a place for drug addicts or alcoholics or a health hydro or natural cure clinic or similar establishment e. is not an institution providing long-term care for the blind deaf dumb or other handicapped persons 10. Illness means any one somatic illness or disease which manifests itself during the period of insurance and includes premature senile degenerative changes but not an illness which is of such a nature as to be incapable of diagnosis by objective evidence or which though capable of diagnosis by such evidence has not been so diagnosed 11. Insured Person means a. A principal Insured Person or an Eligible Spouse of a Principal Insured Person (if spouse s cover has been granted) or an eligible child of a Principal Insured Person (if dependant s cover has been granted) or an Eligible Extended family Dependant (if dependant s cover has been granted). Such persons must be covered in terms of the Principal Insured Person s Medical Scheme and b. such other person as the Company may from time to time deem eligible. 12. Medical practitioner means a legally qualified registered medical practitioner 13. Travelling means travelling in any country other than the Republic of South Africa 14. Treatment means any form of investigation or examination by or consultation with or treatment by a medical practitioner for the purpose of treating or monitoring an insured person s medical condition arising out of an insured incident 15. Admission to Hospital means admission to a hospital ward 16. Insured Incident means any one accident or illness which causes an insured person to be confined to hospital and to undergo certain medical or surgical procedures and/or operations 17. Medical scheme means a registered Medical scheme in terms of the Medical Schemes Act 131 of Schedule means the Schedule attaching to and forming part of this Policy GENERAL MEMORANDA 1. The table of benefits applies in the territory of the Republic of South Africa 2. The Company reserves the right to alter the basis on which the benefit is calculated by giving sixty (60) days written notice of any change to the participating employer or individual member GENERAL EXCEPTIONS The Company shall not be liable for any cost related to or in consequence of, hospitalisation bodily injury sickness or disease directly or indirectly caused by, 1. Co-payments as a result of non-compliance with the medical scheme rules relating to the use of network providers and Designated Service Providers. 2. Shortfalls or co-payments as a result of not following your medical scheme s pre-authorisation and/or referral procedures.

6 3. Nuclear weapons or nuclear material or by ionising radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel. For the purpose of this exception combustion shall include any self-sustaining process of nuclear fission 4. An event directly attributable to the insured person having an alcohol content exceeding eighty (80) milligrams per one hundred (100) millilitres of blood. 5. Participation in a. Active military duty policy duty police reservist duty civil commotion labour disturbances, riots, strikes, the activities of locked out workers or war b. Professional sport and aviation other than as a passenger c. Any form of race or speed test other than on foot or involving any non-mechanically propelled vehicle vessel craft or aircraft 6. Investigations treatment surgery for obesity its sequelae or cosmetic surgery or surgery directly or indirectly caused by or related to or in consequence of cosmetic surgery other than as a result of an insured event otherwise insured 7. Investigations, treatment or surgery for artificial insemination or hormone treatment for infertility 8. Suicide attempted suicide or intentional self-injury 9. The taking of any drug or narcotic unless prescribed by and taken in accordance with the instructions of a registered medical practitioner other than the insured person 10. Depression insanity mental or mental stress-related conditions 11. Investigations, treatment or surgery in respect of dental implants 12. Emergency casualty admissions where the cost of such admission has been paid from the risk portion of the medical scheme 13. Any procedure or code not covered or declined or paid as an exception by the medical scheme 14. Admin fees, levies or doctors co-payments paid directly to the doctor or specialist and not related to the medical scheme 15. No benefits are payable for ward fees, theatre fees or other hospital expenses. 16. Any cost or shortfall due to you exceeding your overall annual limit on your medical scheme. 17. Any pre-existing form of cancer will exclude you from claiming for the Cancer lump-sum benefit. GENERAL CONDITIONS 1. Claims a. Following an insured incident (as defined) the Principal Insured Person shall at his own expense: i. as soon as possible notify the administrator of any claim in writing but not later than one hundred and eighty (180) days from treatment for such incident ii. supply in writing any such proof or other information as the Company may reasonably request iii. as often as required, provide authority for the Company to inspect all current and/or past medical or other information including the results of any blood tests and submit to medical examination on behalf of and at the expense of the Company iv. where the Insured Person is not a Principal Insured Person the Principal Insured Person shall provide or obtain the necessary permission or consent to comply with this condition failing which all benefits in respect of any claims subject to this condition shall be avoidable

7 b. Any claim in terms of this policy will prescribe after twelve (12) calendar months from the date of occurrence of the insured incident if the claim is outstanding and not a subject of a then pending court case c. Where the Company rejects or disputes a claim or the quantum of a claim, or voids the policy, the Principal Insured has ninety (90) days (the representation period ) from receipt of the Company s written notification to dispute the decision of the Company. This must be done in writing to the Company: The Operational Officer Constantia Insurance Company Limited PO Box 3518 Cramerview 2060 Tel: Fax: info@constantiagroup.co.za Alternatively, the Principal Insured may contact: The Ombudsman for Short-Term Insurance PO Box Braamfontein, 2017 Tel: Fax: If the dispute is not satisfactorily resolved in this manner, the Principal Insured has a further 180 (one hundred and eighty) days after the expiry of the representation period for the service of summons on the Company. 2. Premiums a. Annual premiums due may be paid in monthly instalments each of which will be due on the first day of each calendar month during the period of insurance but payable not later than the seventh (7 th ) day following the calendar month for which premium is due b. Due date will be the first day of every calendar month c. A full month s premium is due in respect of any insured person whose cover commences or ceases during a calendar month if such person enjoyed cover for fifteen (15) days or more in that particular month d. The premium is due monthly in arrears and if it is not received by the Company by the seventh (7 th ) day following the calendar month for which the premium is due then this policy shall be suspended e. Subject to the approval of the Company the Policy may be reinstated on receipt of arrears payment 3. Termination of cover a. This policy may be cancelled at any time by the Company giving sixty (60) days notice in writing b. The participating group may cancel this policy at any time by giving sixty (60) days notice in writing c. An incident will only qualify if the hospitalisation caused by such incident commences before the date of cancellation in which case all outstanding claims must be submitted to the Company within two (2) months after the date of cancellation d. A member participating in a group scheme must remain on cover until 31 December or termination of employment. The member may cancel his policy on 31 December giving thirty (30) days notice in writing. 4. Medical examination Payment of any benefit is conditional on the Insured supplying such medical evidence as is required and if requested by the Company an insured person undergoing any medical examination at the Company s expense

8 5. Jurisdiction The policy shall be subject to the laws of the Republic of South Africa whose courts shall have sole jurisdiction to the exclusion of the courts of any other country Where payment is to be made to or by the Company it shall be made in the currency of the Republic of South Africa at the company s head office unless the Company allows otherwise 6. Commencement of cover a. Cover in terms of this policy commences after a waiting period specified in the Schedule; b. A full month s premium is due in respect of any insured person whose cover commences or ceases during a calendar month if such person enjoyed cover for fifteen (15) days or more in that particular month 7. Amendments The company reserves the right to adjust the premiums by giving sixty (60) days written notice 8. Premium payment The Company shall not be obliged to accept premium tendered to it after inception date or renewal date as the case may be but may do so upon such terms as it at its sole discretion may determine 9. Cooling off period A Principal Insured Person may: a. in any case where no benefit has yet been paid or aimed or an insured incident has not yet occurred and b. within a period of 30 days of receipt of the policy by the Principal Insured, or from a reasonable date on which it can be deemed that the policyholder received the policy referred to above, cancel the policy by written notice sent to the Underwriting Manager. c. All premiums or moneys paid by the policyholder to the insurer up to the date of receipt of the cancellation notice or received at any date thereafter in respect of the cancelled or varied policy, shall be refunded to the policyholder. 10. Cover a. Cover shall only be in force provided that the Insured Person is an active employee or pensioner of the Nedgroup. b. No benefit shall be payable in respect of any medical or surgical treatment unless such treatment occurred during the period of hospital confinement as an in-patient or during chemotherapy or radiotherapy as an out-patient for the treatment of cancer or during treatment as an out-patient for the necessity of kidney dialysis. c. Unless in the event of an accident or medical emergency no benefit shall be payable in respect of any medical or surgical treatment unless pre-authorisation by the medical scheme was provided as prescribed by the medical scheme. 11. Conditions of Membership a. On becoming a Member each Principal Insured and their Dependents shall be deemed to have accepted the terms and conditions of this Policy and thus agree to be bound by them. b. It is a condition of membership that each Principal Insured person and Dependant is a member of a Medical Scheme registered in terms of the Medical Schemes Act. c. It is a condition of membership that each Principal Insured person is a full time or part time active employee or pensioner of the participating employer group.

9 DEFINED EVENTS In the event of an insured person suffering an insured incident (as defined) which necessitates the insured person: 1. Being confined to hospital and 2. Undergoing medical or surgical procedures and/or operations (as defined) or treatment (as defined) whilst in hospital including: d. The necessity for chemotherapy or radiotherapy for the treatment of cancer on an outpatient basis e. The necessity for kidney dialysis on an out-patient basis, 3. The necessity for outpatient diagnostic radiology limited to: a. Magnetic Resonance Imaging (MRI) b. Computed Tomography Scans (CT Scans) 4. The necessity for outpatient treatment for the following procedures: I. General Surgery i. Surgical biopsy of breast lump ii. Hernia repairs Inguinal hernia Femoral hernia Umbilical hernia Epigastric hernia Spigelian hernia iii. Ischio-rectal abscess drainage iv. Closure of colostomy v. Surgical haemorrhoidectomy (excluding sclerotherapy or band ligation) vi. Lymph node biopsy vii. Endoscopy viii. Bone marrow biopsy ix. Biopsy of skin x. Stitching of wound II. Urology i. Vasectomy ii. Cystoscopy iii. Orchidopexy iv. Prostate biopsy III. Opthalmology i. Cataract removal ii. Pterygium removal iii. Trabeculectomy IV. ENT surgery i. Direct laryngoscopy ii. Tonsillectomy iii. Laser ENT Surgery iv. Conventional ENT Surgery v. Nasal surgery (Turbinectomy and Septoplasty) vi. Sinus surgery (FESS) vii. Myringotomy viii. Grommets V. Orthopaedic i. Arthroscopy ii. Carpal Tunnel Release iii. Ganglion surgery iv. Bunionectomy VI. Paediatric surgery i. Orchidopexy VII. Hepatobiliary surgery i. Needle biopsy of the liver VIII. Cardiothoracic surgery i. Bronchoscopy IX. General medical cardiology i. Coronary angioplasty ii. Coronary angiogram X. Neurology i. 48-hour halter EEG XI. Immunology i. Plasmatheresis XII. Gastroenterology i. Oesophagoscopy ii. Gastroscopy iii. Colonoscopy iv. ERCP XIII. Diagnostic radiology i. Myelogram ii. Bronchograhy iii. Angiograms Carotid Cerebral Coronary Peripheral XIV. Obstetrics & gynaecology i. Tubal ligation ii. Childbirth in a non-hospital setting iii. Incision and drainage of Bartholin s cyst iv. Marsupilisation of Bartholin s cyst v. Cervical laser ablation vi. Hysteroscopy vii. Phototherapy viii. Dilation and curettage XV. Hyperbaric oxygen treatment for: i. Radionecrosis ii. Malunion of major fractures iii. Avascular leg ulcers iv. Decompression sickness v. Chronic osteitis vi. Serious anaerobic infections The Company will pay to the principal insured person an amount in accordance with the table of benefits subject to the limitations

10 TABLE OF BENEFITS In the event that a Member (as defined) suffered an incident (As defined) resulting in a shortfall of Medical Scheme Benefits but limited to: 1. Charges for services provided by a Medical Practitioner (as defined) above the Medical Scheme tariff not met by the Medical scheme for treatment received whilst as an in-patient and/or outpatient (as stated in the Defined Event). The benefit is limited to five (5) times the Medical Scheme tariff. 2. The requirement in the rules of the Medical Scheme (as defined) that the member contributes in the form of a co-payment or an upfront deductible amount for the cost of a medical or surgical procedure regardless of the cost of such procedure for treatment received whilst as an in-patient and/or outpatient (as stated in the Defined Event). 3. The cost for medical or surgical procedures or the cost of internal prosthesis above a sublimitation in terms of the Medical Scheme rules. 4. Charges above the Medical Scheme tariff for medicine, materials and appliances not met by the Medical scheme. 5. Following an Emergency (as defined) all costs incurred for any Investigations treatment and/or surgery in a hospital emergency unit. 6. On the death or permanent and total disablement of an insured person resulting from an accident (as defined) a once off R lump sum will be paid. 7. On the diagnosis of cancer, where there were no previous diagnosis of any other cancer, a once off R lump sum will be paid. 8. On the death or permanent and total disability of the principal member a benefit equal to the cost of the medical scheme premium (at the same level of cover) for a period of 6 months, limited to a maximum premium of R3 000 per month. OVERALL LIMITATIONS a. No overall limit applies for charges above the Medical Scheme tariff but he benefit is limited to 5 (five) time (500%) of the base scheme reimbursement rate. b. No overall limit applies to charges for standard co-payments and or deductibles charged in terms of the Medical Scheme rules. c. The cost of a medical or surgical procedure or the cost of internal prosthesis above a sub-limitation in terms of the Medical Scheme rules shall be limited to a total benefit of R per family per annum. d. Any benefits provided for Emergency treatment shall be limited to R per family per annum. e. The medical scheme premium waiver cover is limited to R3 000 per month and will only be paid for a period of 6 (six) months. f. The lump sum benefit on the death or total and permanent disablement due to an accident will be limited to R per event. g. The lump sum benefit on the first time diagnosis of any form of cancer will be limited to R per event.

11 SCHEDULE OF INSURANCE This Schedule serves as a contract of insurance between the Insured Person and the Company and forms part of the Company's Policy Wording (detailed below) under which benefits are provided as stated therein and must be read in conjunction with same. All Premiums and Fees are inclusive of 14% and this Schedule becomes a Tax Invoice once Premium and Fees have been accepted by the Company, Broker and Administrator respectively. PRODUCT: AUH GAP NEDGROUP OPTION 1 INSURER (the Company): Constantia Insurance Company Limited, FSP No , Vat No THE INSURED: African Unity Health (Pty) Ltd THE INSURED PERSONS: Principal Members of the insured, as accede to the Policy as evidenced by monthly bordereaux. POLICY NO.: AUH NED1 PERIOD OF INSURANCE: a. From: 1 ST January 2016 to 31 ST December 2016 (both days inclusive) b. Plus any subsequent period for which the company agrees to accept a renewal premium. TERRITORIAL LIMITS: SADC territories MONTHLY PREMIUMS MONTHLY BROKER COMMISSION: R MONTHLY ADMINISTRATOR FEE: R MONTHLY RISK PREMIUM: R TOTAL MONTHLY PAYMENT DUE: R Note: PREMIUM COLLECTION: PAYMENT OBLIGATION: Please note that the abovementioned commissions are in accordance with legislation whereby, of Premium due, no more than 20% and 12.50% may be paid by way of commission for non-motor and motor risks respectively. Direct Debit Order You have an obligation to pay your premium if you are to enjoy cover. This is a monthly policy and the due date for the payment of the full premium is paid in arrears on a monthly basis in accordance with the above mentioned Payment Date via the above mentioned Premium Collection Method. Please note that if you do not pay your premium within 15 days following the month in which premium was due, your cover will be terminated from midnight on the day prior to the month in which premium was due.

12 AUH GAP NEDGROUP OPTION 2 MASTER POLICY NO: AUH NED2 ISSUED TO AFRICAN UNITY HEALTH (PTY) LTD

13 In consideration of and conditional upon the prior payment of the premium by or on behalf of the Insured and the receipt thereof by or on behalf of Constantia Insurance Company Limited, (the Company) before the inception date or renewal date (as the case may be) and subject to the terms exceptions conditions and provisions of the policy the Company agrees to pay the principal insured person for an insured incident occurring during the period of insurance up to the limit of indemnity stated for the insured person and the benefit as stated in each section of the Policy DEFINITIONS In this policy words importing the masculine gender shall be deemed to include the feminine gender and words importing the singular number shall be deemed to include the plural number and vice versa, and the following expressions shall have the following meanings: 1. Accident means bodily injury caused by violent accidental and external physical means 2. Biological Cancer Drug means a substance that is made from a living organism or its products and is used in the prevention, diagnosis, or treatment of cancer. For the purpose of this Policy Biological Drugs include antibodies, interleukins, and vaccines. 3. Eligible child means a child including a legally adopted child or stepchild who has not attained the age of twenty three (23) of a principal insured who is not already insured under this policy or any other insurance issued by the Company providing similar cover This age may be extended to 25 in respect of an unmarried child who is a full time student. There will be no age restriction for children who are either mentally or physically incapacitated from maintaining themselves, always provided that the children are wholly dependent on the Principal Member for support and maintenance. Once a child has become independent of the principle member for support and maintenance, dependency and therefore definition of a child cannot be revived at a later date unless that child is still under the age of twenty one (21). 4. Eligible member means a principal insured person who is in a category of paid up members as designated by the Insured and accepted by the Company as eligible for participation in the insurance provided by this policy and such other person as the Company may from time to time deem eligible. 5. Eligible spouse the spouse of the principal insured person who is not already insured under this section or any other policy issued by the Company providing similar cover Where a person shares an abode with a principal insured person and has done so for at least six (6) months and lives together in the manner of a legally married couple the person shall be regarded as a spouse. Should a principal insured person have more than one spouse who could qualify as an eligible spouse then any claim shall determine that that principal insured person has made an irrevocable nomination of one eligible spouse to whom the benefits shall apply 6. Eligible Extended family Dependant means any other adult dependant that is registered as an adult dependant of or alongside the Principal Insured Person. 7. Emergency means an admission to a hospital emergency unit following an event of a 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 8. Family means the principal insured person and such person s eligible spouse provided such spouse is an insured person but not a principal insured person and such person s eligible children provided they are insured persons

14 9. Hospital means any institution in the territory of RSA which in the opinion of the Company meets each of the following criteria: a. Has diagnostic and therapeutic facilities for surgical and medical diagnosis treatment and care of insured and sick persons by or under the supervision of a staff of medical practitioners b. Provides nursing service supervised by registered nurses or nurses with equivalent qualifications c. is not other than incidentally either a mental institution or a convalescent home d. is not a place of rest for the aged or a place for drug addicts or alcoholics or a health hydro or natural cure clinic or similar establishment e. is not an institution providing long-term care for the blind deaf dumb or other handicapped persons 10. Illness means any one somatic illness or disease which manifests itself during the period of insurance and includes premature senile degenerative changes but not an illness which is of such a nature as to be incapable of diagnosis by objective evidence or which though capable of diagnosis by such evidence has not been so diagnosed 11. Insured Person means a. A principal Insured Person or an Eligible Spouse of a Principal Insured Person (if spouse s cover has been granted) or an eligible child of a Principal Insured Person (if dependant s cover has been granted) or an Eligible Extended family Dependant (if dependant s cover has been granted). Such persons must be covered in terms of the Principal Insured Person s Medical Scheme and b. such other person as the Company may from time to time deem eligible. 12. Medical practitioner means a legally qualified registered medical practitioner 13. Travelling means travelling in any country other than the Republic of South Africa 14. Treatment means any form of investigation or examination by or consultation with or treatment by a medical practitioner for the purpose of treating or monitoring an insured person s medical condition arising out of an insured incident 15. Admission to Hospital means admission to a hospital ward 16. Insured Incident means any one accident or illness which causes an insured person to be confined to hospital and to undergo certain medical or surgical procedures and/or operations 17. Medical scheme means a registered Medical scheme in terms of the Medical Schemes Act 131 of Schedule means the Schedule attaching to and forming part of this Policy GENERAL MEMORANDA 1. The table of benefits applies in the territory of the Republic of South Africa 2. The Company reserves the right to alter the basis on which the benefit is calculated by giving sixty (60) days written notice of any change to the participating employer or individual member GENERAL EXCEPTIONS The Company shall not be liable for any cost related to or in consequence of, hospitalisation bodily injury sickness or disease directly or indirectly caused by, 1. Co-payments as a result of non-compliance with the medical scheme rules relating to the use of network providers. 2. Shortfalls or co-payments as a result of not following your medical scheme s pre-authorisation and/or referral procedures

15 3. Nuclear weapons or nuclear material or by ionising radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel. For the purpose of this exception combustion shall include any self-sustaining process of nuclear fission 4. An event directly attributable to the insured person having an alcohol content exceeding eighty (80) milligrams per one hundred (100) millilitres of blood. 5. Participation in a. Active military duty policy duty police reservist duty civil commotion labour disturbances, riots, strikes, the activities of locked out workers or war b. Professional sport and aviation other than as a passenger c. Any form of race or speed test other than on foot or involving any non-mechanically propelled vehicle vessel craft or aircraft 6. Investigations treatment surgery for obesity its sequelae or cosmetic surgery or surgery directly or indirectly caused by or related to or in consequence of cosmetic surgery other than as a result of an insured event otherwise insured 7. Investigations, treatment or surgery for artificial insemination or hormone treatment for infertility 8. Suicide attempted suicide or intentional self-injury 9. The taking of any drug or narcotic unless prescribed by and taken in accordance with the instructions of a registered medical practitioner other than the insured person 10. Depression insanity mental or mental stress-related conditions 11. Investigations, treatment or surgery in respect of dental implants 12. Emergency casualty admissions where the cost of such admission has been paid from the risk portion of the medical scheme 13. Any procedure or code not covered or declined or paid as an exception by the medical scheme 14. Admin fees, levies or doctors co-payments paid directly to the doctor or specialist and not related to the medical scheme 15. No benefits are payable for ward fees, theatre fees or other hospital expenses. 16. Any cost or shortfall due to you exceeding your overall annual limit on your medical scheme. 17. Any pre-existing form of cancer will exclude you from claiming for the Cancer lump-sum benefit. GENERAL CONDITIONS 1. Claims a. Following an insured incident (as defined) the Principal Insured Person shall at his own expense: i. as soon as possible notify the administrator of any claim in writing but not later than one hundred and eighty (180) days from treatment for such incident ii. supply in writing any such proof or other information as the Company may reasonably request iii. as often as required, provide authority for the Company to inspect all current and/or past medical or other information including the results of any blood tests and submit to medical examination on behalf of and at the expense of the Company iv. where the Insured Person is not a Principal Insured Person the Principal Insured Person shall provide or obtain the necessary permission or consent to comply with this condition failing which all benefits in respect of any claims subject to this condition shall be avoidable

16 b. Any claim in terms of this policy will prescribe after twelve (12) calendar months from the date of occurrence of the insured incident if the claim is outstanding and not a subject of a then pending court case c. Where the Company rejects or disputes a claim or the quantum of a claim, or voids the policy, the Principal Insured has ninety (90) days (the representation period ) from receipt of the Company s written notification to dispute the decision of the Company. This must be done in writing to the Company: The Operational Officer Constantia Insurance Company Limited PO Box 3518 Cramerview 2060 Tel: Fax: info@constantiagroup.co.za Alternatively, the Principal Insured may contact: The Ombudsman for Short-Term Insurance PO Box Braamfontein, 2017 Tel: Fax: If the dispute is not satisfactorily resolved in this manner, the Principal Insured has a further 180 (one hundred and eighty) days after the expiry of the representation period for the service of summons on the Company. 2. Premiums a. Annual premiums due may be paid in monthly instalments each of which will be due on the first day of each calendar month during the period of insurance but payable not later than the seventh (7 th ) day following the calendar month for which premium is due b. Due date will be the first day of every calendar month c. A full month s premium is due in respect of any insured person whose cover commences or ceases during a calendar month if such person enjoyed cover for fifteen (15) days or more in that particular month d. The premium is due monthly in arrears and if it is not received by the Company by the seventh (7 th ) day following the calendar month for which the premium is due then this policy shall be suspended e. Subject to the approval of the Company the Policy may be reinstated on receipt of arrears payment 3. Termination of cover a. This policy may be cancelled at any time by the Company giving sixty (60) days notice in writing b. The participating group may cancel this policy at any time by giving sixty (60) days notice in writing c. An incident will only qualify if the hospitalisation caused by such incident commences before the date of cancellation in which case all outstanding claims must be submitted to the Company within two (2) months after the date of cancellation d. A member participating in a group scheme must remain on cover until 31 December or termination of employment. The member may cancel his policy on 31 December giving thirty (30) days notice in writing. 4. Medical examination Payment of any benefit is conditional on the Insured supplying such medical evidence as is required and if requested by the Company an insured person undergoing any medical examination at the Company s expense

17 5. Jurisdiction The policy shall be subject to the laws of the Republic of South Africa whose courts shall have sole jurisdiction to the exclusion of the courts of any other country Where payment is to be made to or by the Company it shall be made in the currency of the Republic of South Africa at the company s head office unless the Company allows otherwise 6. Commencement of cover a. Cover in terms of this policy commences after a waiting period specified in the Schedule; b. A full month s premium is due in respect of any insured person whose cover commences or ceases during a calendar month if such person enjoyed cover for fifteen (15) days or more in that particular month 7. Amendments The company reserves the right to adjust the premiums by giving sixty (60) days written notice 8. Premium payment The Company shall not be obliged to accept premium tendered to it after inception date or renewal date as the case may be but may do so upon such terms as it at its sole discretion may determine, 9. Cooling off period A Principal Insured Person may: a. in any case where no benefit has yet been paid or aimed or an insured incident has not yet occurred and b. within a period of 30 days of receipt of the policy by the Principal Insured, or from a reasonable date on which it can be deemed that the policyholder received the policy referred to above, cancel the policy by written notice sent to the Underwriting Manager. c. All premiums or moneys paid by the policyholder to the insurer up to the date of receipt of the cancellation notice or received at any date thereafter in respect of the cancelled or varied policy, shall be refunded to the policyholder. 10. Cover a. Cover shall only be in force provided that the Insured Person is an active employee or pensioner of the Nedgroup. b. No benefit shall be payable in respect of any medical or surgical treatment unless such treatment occurred during the period of hospital confinement as an in-patient or during chemotherapy or radiotherapy as an out-patient for the treatment of cancer or during treatment as an out-patient for the necessity of kidney dialysis. c. Unless in the event of an accident or medical emergency no benefit shall be payable in respect of any medical or surgical treatment unless pre-authorisation by the medical scheme was provided as prescribed by the medical scheme. 11. Conditions of Membership a. On becoming a Member each Principal Insured and their Dependents shall be deemed to have accepted the terms and conditions of this Policy and thus agree to be bound by them. b. It is a condition of membership that each Principal Insured person and Dependant is a member of a Medical Scheme registered in terms of the Medical Schemes Act. c. It is a condition of membership that each Principal Insured person is a full time or part time active employee or pensioner of the participating employer group.

18 DEFINED EVENTS In the event of an insured person suffering an insured incident (as defined) which necessitates the insured person: 1. Being confined to hospital and 2. Undergoing medical or surgical procedures and/or operations (as defined) or treatment (as defined) whilst in hospital including: d. The necessity for chemotherapy or radiotherapy for the treatment of cancer on an outpatient basis e. The necessity for kidney dialysis on an out-patient basis, 3. The necessity for outpatient diagnostic radiology limited to: a. Magnetic Resonance Imaging (MRI) b. Computed Tomography Scans (CT Scans) 4. The necessity for outpatient treatment for the following procedures: I. General Surgery i. Surgical biopsy of breast lump ii. Hernia repairs Inguinal hernia Femoral hernia Umbilical hernia Epigastric hernia Spigelian hernia iii. Ischio-rectal abscess drainage iv. Closure of colostomy v. Surgical haemorrhoidectomy (excluding sclerotherapy or band ligation) vi. Lymph node biopsy vii. Endoscopy viii. Bone marrow biopsy ix. Biopsy of skin x. Stitching of wound II. Urology i. Vasectomy ii. Cystoscopy iii. Orchidopexy iv. Prostate biopsy III. Opthalmology i. Cataract removal ii. Pterygium removal iii. Trabeculectomy IV. ENT surgery i. Direct laryngoscopy ii. Tonsillectomy iii. Laser ENT Surgery iv. Conventional ENT Surgery v. Nasal surgery (Turbinectomy and Septoplasty) vi. Sinus surgery (FESS) vii. Myringotomy viii. Grommets V. Orthopaedic i. Arthroscopy ii. Carpal Tunnel Release iii. Ganglion surgery iv. Bunionectomy VI. Paediatric surgery i. Orchidopexy VII. Hepatobiliary surgery i. Needle biopsy of the liver VIII. Cardiothoracic surgery i. Bronchoscopy IX. General medical cardiology i. Coronary angioplasty ii. Coronary angiogram X. Neurology i. 48-hour halter EEG XI. Immunology i. Plasmatheresis XII. Gastroenterology i. Oesophagoscopy ii. Gastroscopy iii. Colonoscopy iv. ERCP XIII. Diagnostic radiology i. Myelogram ii. Bronchograhy iii. Angiograms Carotid Cerebral Coronary Peripheral XIV. Obstetrics & gynaecology i. Tubal ligation ii. Childbirth in a non-hospital setting iii. Incision and drainage of Bartholin s cyst iv. Marsupilisation of Bartholin s cyst v. Cervical laser ablation vi. Hysteroscopy vii. Phototherapy viii. Dilation and curettage XV. Hyperbaric oxygen treatment for: i. Radionecrosis ii. Malunion of major fractures iii. Avascular leg ulcers iv. Decompression sickness v. Chronic osteitis vi. Serious anaerobic infections The Company will pay to the principal insured person an amount in accordance with the table of benefits subject to the limitations