YOUR WAITING PERIODS
From the first day that your cover starts with us, waiting periods will apply before you are able to claim any of your policy benefits.
THREE MONTH GENERAL WAITING PERIOD
Within the first 3 months of cover a general waiting period will apply, where no claims can be submitted unless you are claiming for an injury resulting from an accident caused by physical impact.
12 MONTH PRE-EXISTING CONDITION SPECIFIC WAITING PERIOD
Within the first 12 months of cover a waiting period for pre-existing medical conditions will apply, where no claims can be submitted for a procedure, surgery, treatment or an investigation relating to any illness or condition for which you received advice or treatment 12 months prior to your cover start date.
PRE-DIAGNOSED CANCER WAITING PERIOD
Where cancer is diagnosed before the first day your cover starts, all cancer and related claims can only be submitted after you have been in remission for a minimum period of 3 consecutive years from the date you are confirmed to be in remission.
We do not cover service providers’ accounts for related medical procedures and / or treatment, hospitalisation, illness, disease, loss, damage, death, bodily injury or liability that is caused by or results from:
1. An event where the claimant is not an insured person at the time of the event, unless a benefit specifically makes provision for cover.
2. Medical scheme exclusions where no underlying cover exists, unless a benefit specifically makes provision for cover.
3. An event where a benefit limit or an Overall Policy Limit (OPL) has been reached.
4. An event where the policy does not provide the relevant benefit to claim from.
5. An event where pre-authorisation was not obtained from the medical scheme or where medical scheme rules were not followed.
6. An event where the use of a hospital, day-clinic or service provider was voluntary and the service provider does not form part of the medical scheme’s network, unless a benefit specifically makes provision for cover.
7. An event that occurs during a policy waiting period, unless otherwise specified.
8. Maxillo-facial surgery and related medical conditions and / or medical procedures unless due to accidental impact resulting in severe physical injury.
9. Dental implants, orthodontic, prosthodontic or cosmetic dentistry.
10. External prostheses or appliances such as artificial limbs, wheelchairs and crutches.
11. Robotic surgery, specialised mechanical or computerised appliances and equipment.
12. Artificial insemination, infertility treatment or contraceptives except for tubal ligation and vasectomies.
14. Non-medically necessary reconstructive cosmetic surgery.
15. Breast reconstruction performed as a second or subsequent reconstruction.
16. Home nursing or admission to a step-down facility such as a frail care centre, unless a benefit specifically makes provision for cover.
17. Depression, insanity, emotional or mental illness or any stress-related conditions.
18. Costs associated with supporting medical reports that assist in the finalisation of a claim.
19. Routine physical, diagnostic procedures or examination where there are no objective indications of impairment in normal health.
20. Expenses incurred for transport charges or for services rendered whilst being transported in an emergency vehicle, vessel or aircraft.
21. Riots, wars, political acts, public disorder, terrorism, civil commotions, labour disturbances, strikes, lock-out, or any attempted such acts.
22. A deliberate criminal or fraudulent act or any illegal activity conducted by you or a member of your household which directly or indirectly results in loss, damage or injury.
23. Attempted suicide, intentional self-injury and deliberate exposure to exceptional danger except in an attempt to save a human life.
24. An event where the use of drugs or alcohol is involved.
25. Active military, police and police reservist activities whilst on active duty.
26. Nuclear weapons material, ionising radiations or contamination by radioactivity from any nuclear fuel, nuclear waste or from the combustion of nuclear fuel that includes any self sustaining process of nuclear fission.
27. Events that occur for which the actual damage is provided for by legislation, including contractual liability and consequential loss.
28. Discounts negotiated by an insured person directly with a service provider where reimbursement of a claim will enrich the insured person.
29. Non-disclosure of material information that is likely to affect the assessment or acceptance of risk.