ADMED - Frequently Asked Questions

Transcription

1 ADMED - Frequently Asked Questins WHAT DOES ADMED COVER? The shrtfall, r gap, is defined as the amunt by which the actual cst, nt exceeding the Admed Tariff, less the actual amunt payable by the medical scheme. WHAT IS Admed Tariff? Previusly knwn as the Reference Price List (RPL) published by the Department f Health. This list has been maintained by Guardrisk thrugh increasing the Tariffs by inflatin each year. WHEN DOES ADMED APPLY AND WHEN DOES IT NOT APPLY? It applies nly fr claims incurred while yu are Hspitalised (peratin, accident, illness etc) and fr certain prcedures perfrmed n an ut-patient basis (day-t-day services) at a dctr s surgery like a gastrscpy, clnscpy, remval f cataracts and certain bipsies. It des nt apply fr day t day services ie. Dentistry, Optmetry, medicatin, GP r specialist visits etc. It des nt cver the Hspital stay, materials and prsthesis (depending n prduct type). WHAT IS A STATED BENEFIT? A benefit payable t the insured fr unfreseen csts incurred fr an event perfrmed in hspital subject t a maximum f R per annum per family. This wuld typically cver c-payments and deductibles. This benefit includes c-payments f MRI/ CT and PET scans. ONCOLOGY BENEFIT DOES THE BENEFIT ONLY APPLY TO THE ONCOLOGY CO-PAYMENT? This benefit nly applies t the c-payment. The benefit will pay up t a maximum f 20% c-payment nce the member s nclgy benefit has been exhausted subject t the R per beneficiary per persn per annum. SHOULD THE MEMBER BE REGISTERED ON THE ONCOLOGY PROGRAMME? Yes, the member has t be registered n the medical scheme s nclgy prgramme. DO MEMBERS ONLY QUALIFY FOR THE BREAST AND PROSTRATE CANCER BENEFIT ON FIRST TIME DIAGNOSIS? Yes, Members will receive a nce ff benefit f R n first time diagnsis f breast r prstate cancer during the insured perid HOW MUCH DOES IT COST & IS THERE ANY AGE RESTRICTION UPON JOINING THE POLICY? Admed is a grup rated plicy. Therefre, a grup rate will be applicable irrespective f the size f yur family. There is n age restrictin upn jining the plicy.

2 WHO CAN JOIN ADMED? Any member wh is registered as a principal member r a dependant n a medical aid scheme. WHAT PROOF OF MEMBERSHIP DO YOU RECEIVE AS A MEMBER? All members wh jin Admed will receive a Membership Certificate (indicating a unique member number) and a Plicy Dcument. HOW AND WHEN DO MEMBERS CLAIM FROM ADMED? Members have 6 mnths frm the date f admissin t hspital r ther qualifying event, t ntify Guardrisk in writing, f the claim. Members are hwever encuraged t submit a claim as sn as pssible after the event. Members can btain claim frms directly frm Guardrisk. HOW IS THE BENEFIT PAID & TO WHOM IS IT PAID? Claim payments under the Admed insurance plicy are depsited directly int the member s bank accunt. The benefit is paid directly t yu and yu are respnsible fr settling the accunts with the dctr. HOW LONG DOES IT TAKE TO PAY A CLAIM? Apprximately 7 wrking days, after receipt f all claim dcumentatin. WHAT DOCUMENTS DO I NEED TO SUBMIT WHEN LODGING A CLAIM? Cmpleted Admed claim frm and all supprting dcuments e.g. hspital accunt, medical practitiner s accunts and medical aid statement. AdmedAdd + members shuld submit invices/receipts when submitting a claim fr the stated benefit prtin. CAN YOU STILL CLAIM IF YOU HAVE GIVEN NOTICE TO LEAVE THE ADMED POLICY? Yes, yu are still cvered until the last day f yur ntice perid and given that yur cntributins are paid up. Claims after that date will nt be prcessed. WHAT DOES ADMED NOT COVER? Please refer t Plicy dcument fr list f exclusins. WHAT ARE THE TYPES OF WAITING PERIODS THE POLICY CAN GIVE YOU? Waiting perids are applicable t Vluntary membership grups. birth related claims: 10 mnths frm date f cmmencement first 6 mnths f cver: 0% benefit secnd 6 mnths f cver : 50% benefit fr: Jint replacements (except as a result f an accident/injury ccurring after jining) Arthrscpic prcedures (except as a result f an accident/ injury ccurring after jining) Spinal surgery including spinal fusin (except as a result f an accident/injury ccurring after jining) Nasal surgery including sinus related (except as a result f an accident/injury ccurring after jining) Cataract surgery Hysterectmy (except fr cancer diagnsed after jining) Dentistry related claims (except recnstructive as a result f an accident/injury ccurring after jining) All hernia repairs (except as a result f an accident/injury ccurring after jining) and All cardiac related surgery and prcedures (including angiplasty, cardiac catheterizatin etc.) diagnsed prir t date f jining. In cnjunctin with the abve a 3 mnth general waiting perid wuld be applied t all individual membership nt linked t a grup scheme.

3 WHAT DOES A WAITING PERIOD MEAN? Perid during which a member has t pay his nrmal mnthly cntributin but is nt entitled t claim any benefits frm the plicy. WHO QUALIFIES AS A DEPENDANT? A Child, including legally adpted child r stepchild f a Principal Insured Persn and wh is registered as their dependant n a medical aid scheme. The Spuse, f a Principal Insured Persn and wh is registered as their dependant n a medical aid scheme. A Parent r Sibling f a Principal Insured Persn and wh is registered as their dependant n a medical aid scheme. CAN GUARDRISK TERMINATE MY ADMED MEMBERSHIP? Yes, n nn-payment f premiums. WHAT HAPPENS IF AS THE PRINCIPAL INSURED I PASS AWAY BEFORE MY SPOUSE? Yur spuse culd still cntinue the cver shuld they elect t d s prvided they infrm the Administratr in writing within 60 days. MUST I GIVE NOTICE TO THE POLICY ADMINISTRATOR IF I WANT TO TERMINATE MY ADMED MEMBERSHIP? Yes, we require a calendar mnth s written ntice f yur intentin t leave the plicy HOW IS THE PREMIUM COLLECTED? Thrugh a debit rder facility IS ADMED A REGISTERED POLICY? Admed is a registered shrt-term Insurance Health and Accident plicy. WHICH INSURER UNDERWRITES THIS POLICY? The plicy is underwritten by Guardrisk Insurance Cmpany Limited, which is a whlly wned subsidiary f Alexander Frbes ne f Suth Africa's leading financial service cmpanies in Suth Africa. WILL I BE RQUIRED TO GO FOR A MEDICAL EXAMINATION TO QUALIFY FOR THE POLICY? There are n medicals required when applying fr this plicy and cver is immediately available. IS THE POLICY ONLY AVAILABLE OR LIMITED TO CERTAIN MEDICAL SCHEMES? N, the plicy is available t any member belnging t a registered medical aid scheme. IS ADMED A CONTINUOUS POLICY OR DO I HAVE TO APPLY EVERY YEAR? Admed membership autmatically rlls-ver t the new plicy perid, unless the member elects nt t cntinue with his/her membership. DOES THIS POLICY HAVE A SURRENDER VALUE? There is n savings r endwment prtin and there is therefre n surrender value n the plicy.

4 ADMED Frequently Asked Questins PERSONAL ACCIDENT SECTION Permanent Disability WHO CAN CLAIM UNDER THE PERSONAL ACCIDENT SECTION? The Persnal Accident benefit is available t All insured members at n additinal csts. WHAT IS DEFINED AS AN ACCIDENT? An Accident is ANY event that results in yur bdy being unintentinally injured. Examples f Accidents can be as fllws: Mtr Vehicle Accidents (MVA s), Recreatinal Sprts Injuries, Injuries n Duty, Injuries at Hme, Snake, Dg and/r Spider Bites, Hi-Jacking and/r Assault WHAT DOES IT MEAN TO BE PERMANENTLY DISABLED? Permanent Disability, bradly speaking, means that yur bdy has been altered / damaged fllwing an Accident, t a severe enugh degree that it will never recver 100%. Sme examples f Permanent Disability can be as fllws: Paraplegia fllwing a Mtr Vehicle Accident here yu wuld qualify fr 100% f the Permanent Disability lump sum benefit Lss f a whle finger fllwing an attack by a dg here yu wuld qualify fr 15% f the Permanent Disability lump sum benefit But, nt all cases can determine the level f Permanent Disability directly after an Accident. If we use the example f a serius multiple bne break in yur leg, fllwing a sprting Accident, the Insurers will require that n-ging medical reprts be supplied t them in rder t plt yur recvery prgress during yur mnths f therapy fllwing a number f peratins. If it is determined that yu have a permanent degree f lss f mvement fllwing therapy, which will never return fully, the Insurer will still cnsider paying a prtin f the Permanent Disability lump sum t yu, as a result f the permanent (thugh nt ttal) damage incurred t yur leg. IS THERE A TIME PERIOD THAT CLAIMS NEED TO BE NOTIFIED IN? Yes, all claims need t be ntified within 180 days fllwing the date f the Accident. HOW LONG DOES IT TAKE BEFORE THE PERMANENT DISABILITY BENEFIT IS PAID? Insurers have up t 24 mnths t determine the level f Permanent Disability prir t releasing the lump sum benefit t the Insured Member. But, as mentined abve, this will be in severe cases where the level f disability cannt be determined directly after an Accident. Each case will be handled individually, but it is imprtant t remember that the claim can nly be assessed nce ALL relevant dcumentatin is received this will include a Medical Certificate (included in the Claim Frm) which requests details f yur injuries as well as recvery prgnsis frm a Medical Practitiner, nging medical reprts (where required) as well as any ther Medical mtivatin required, a cpy f the Traffic Cllisin Reprt (in the event f a Mtr Vehicle Accident), a cpy f the Plice Reprt (in the event f a criminal act e.g. a hijacking, assault etc.) WHAT WILL THE PERSONAL ACCIDENT SECTION NOT COVER? The Insurers shall nt be liable t pay any claim under this Sectin in respect f any Insured Persn 1. while engaging in flying as pilt r member f the crew. This exceptin des nt apply t Insured Persns engaging in ballning, hang-gliding, paragliding and parachuting, prvided that such

5 activities are slely fr scial and/r pleasure purpses and nt f a cmpetitive nature r fr reward 2. caused by the Insured Persn's intentinal self-injury 3. caused slely by an existing physical defect r ther infirmity f the Insured Persn 4. as a result f the influence f alchl, drugs r narctics upn the Insured Persn unless administered by a member f the medical prfessin (ther than himself) r unless prescribed by and taken in accrdance with the instructins f a member f the medical prfessin (ther than himself) 5. caused by the Insured Persn's participatin in any rit r civil cmmtin 6. arising frm war, invasin, act f freign enemy, hstilities (whether war be declared r nt), civil war, rebellin, revlutin, insurrectin, military r usurped pwer 7. as a result f the Insured Persn's deliberate expsure t exceptinal danger (except in an attempt t save human life) r the Insured Persn's wn criminal act 8. while participating in sprt as a prfessinal player. 9. directly r indirectly caused by r cntributed t by r arising frm inising radiatins r cntaminatin by radi-activity frm any nuclear fuel r frm any nuclear waste frm the cmbustin f nuclear fuel r frm any nuclear weapns material. Fr the purpse f this exceptin nly, cmbustin shall include any self-sustaining prcess f nuclear fissin. BESIDES THE PERMANENT DISABILITY LUMP SUM BENEFIT, ARE THERE ADDITIONAL BENEFITS THAT FORM PART OF THE PERSONAL ACCIDENT SECTION? There abslutely are! The fllwing Autmatic Extensins will als be included in yur Plicy, again, at n additinal cst t yu. It is imprtant t remember that these als apply in the event f an Accident: Emergency Transprtatin/Search and Rescue up t R25,000 Life Supprt Equipment up t R25,000 Trauma Cunselling up t R750 per visit, with an annual limit f R25,000 Claims Preparatin Csts up t R20,000 Mbility up t R25,000 Rehabilitatin up t R25,000 RAF Medic Legal Csts up t R10,000 Fr additinal infrmatin n Admed, an explanatin f the Persnal Accident Autmatic Extensins as well as t access the Persnal Accident Claims Guide, please visit ur website, the details f which are : - Under Chse Yur Interest, please select Admed. IF I AM INVOLVED IN AN ACCIDENT BUT AM NOT DISABLED, CAN I STILL CLAIM FROM THE AUTOMATIC EXTENSIONS? Yes yu can. In the event f yur Medical Scheme nt cvering the full cst f the Ambulance, yu can submit a claim under the Emergency Transprtatin Autmatic Extensin, which will pay the balance f the accunt NOT cvered by yur Scheme, up t a maximum f R25,000. It is imprtant t remember that yu will need t attach yur Medical Scheme statement which cnfirms the amunt that has nt been paid by yur scheme. It is equally imprtant t remember that nly Ambulance csts as a result f an Accident will be cvered under this benefit (any illness related transprt csts will unfrtunately nt be cvered under this sectin). ADMED - PERSONAL ACCIDENT AUTOMATIC EXTENSIONS Please nte the additinal Autmatic extensins that are als available when accessing the Accidental Bdily Injury sectin f yur Admed Plicy, where applicable:

6 1. EMERGENCY TRANSPORTATION / SEARCH AND RESCUE maximum f R25,000 The Insurers will pay csts and expenses necessarily incurred fr: 1. emergency transprtatin 2. search and rescue, including freeing and bringing an Insured Persn t a place f safety as a result f, r in rder t prevent, accidental bdily injury t an Insured Persn, prvided that (a) Insurers will nt be liable if an Insured Persn is fund in circumstances which are unlikely t result in accidental bdily injury (b) The maximum amunt payable by Insurers will be R any ne Insured Persn fr each and every claim. 2. LIFE SUPPORT EQUIPMENT maximum f R25,000 The Insurers will pay reasnable csts and expenses, incurred as a result f accidental bdily injury, in respect f hire csts fr life supprt machinery, equipment r apparatus, prvided that the Insurers liability is limited t R any ne Insured Persn fr each and every claim. 3. TRAUMA COUNSELLING up t R750 per visit, with an annual limit f R25,000 If an Insured Persn is subjected t an act f vilence r a traumatic accident, Insurers will reimburse such persn fr cunselling fees actually incurred by such persn as a result f the act f vilence r traumatic accident, prvided that the maximum amunt payable by Insurers will be R750 per visit and R per annum fr each Insured Persn act f vilence shall mean an assault, rbbery, rape, kidnapping r armed car hijack fr the purpses f this extensin nly, Insured Persn shall include immediate family members f such Insured Persn the act f vilence has been reprted t the plice and a case number btained. This extensin als cvers any Insured Persn wh witnesses such an act f vilence r traumatic event, prvided that it arises in the curse f the Insured Persn s emplyment with the Insured. 4. CLAIMS PREPARATION COSTS maximum f R20,000 The insurance by this Plicy extends t include csts reasnably incurred by the Insured in prducing and certifying any particulars r details required by the Insurers t substantiate a claim, prvided that the liability f the Insurers fr such csts fr any ne Insured Persn in respect f each and every claim shall nt exceed the amunt stated in the Schedule. 5. MOBILITY maximum f R25,000 When the Insurers have admitted a claim fr Permanent Disability, if as a direct result f that disability the Insured Persn is permanently dependent n a wheelchair fr mbility, the Insurers will, in additin t any amunt payable fr Permanent Disability, pay fr a self-prpelled wheelchair the fitting f wheelchair lading equipment and alteratins t the Insured Persn's residence t facilitate the use f such wheelchair the mdificatin f the cntrls t the Insured Persn's mtr vehicle prvided that the liability f the Insurers fr such csts in respect f each and every claim shall nt exceed the amunt stated in the Schedule fr any ne Insured Persn. 6. REHABILITATION maximum f R25,000 If an Insured Persn is permanently disabled t the extent that he is unable t fllw his usual business r ccupatin but can be retrained t carry ut anther business r ccupatin, Insurers will, in additin t any Permanent Disability benefit agreed, pay 80% f the retraining csts, plus any csts incurred in adjusting the Insured Persn's wrkplace, prvided that the maximum amunt payable by Insurers will nt exceed the amunt stated in the Schedule fr any ne Insured Persn. 7. RAF MEDICO LEGAL COSTS maximum f R10,000 The insurance by this Plicy is extended t include csts reasnably incurred by the insured Persn, fllwing a mtr vehicle accident, t underg a medical legal examinatin t substantiate a Rad Accident

7 Fund claim, prvided that the liability f the Insurers fr such csts fr any ne Insured Persn in respect f each and every claim shall nt exceed the amunt stated in the Schedule. This extensin will nly apply in cases where the Insurer expects the percentage f partial disability t exceed 30% and the Insurer must first apprve the appintment f a medical legal examinatin. ADMED Frequently Asked Questins ROADCOVER WHO ARE ROADCOVER? RadCver is a Cmpany that assists members by managing Rad Accident Fund (RAF) claims n behalf f the member, frm start t finish! They emply a team f Legal Practitiners t frmulate members claims with the RAF, and as a result f their expertise, can assist members in reducing the claim turnarund time. IS THERE AN ADDITIONAL FEE THAT NEEDS TO BE PAID FOR THIS SERVICE? Abslutely nt! Any cmpensatin received frm the Rad Accident Fund n behalf f a member will be paid ver in FULL. WHO IS COVERED UNDER THE ROADCOVER SECTION OF ADMED? The Principal Member n Admed, as well as any registered dependants n the Principal Member s Medical Scheme membership, wh therefre als qualify fr Admed cver. WHAT CAN MEMBERS EXPECT FROM ROADCOVER, WITH REGARDS TO THEIR SERVICES? Fr the duratin f the claim, members will receive the fllwing: Legal representatin Administratin and claims management Accident recnstructin Required Medic-Legal reprts, Actuarial reprts, past and future lss f earnings reprts as well as past and future lss f supprt reprts WHO IS ENTITLED TO CLAIM FROM THE ROAD ACCIDENT FUND VIA ROADCOVER? A persn wh was persnally injured (except a driver wh was the sle cause f an accident). A dependant f the deceased victim A clse relative f the deceased in respect f funeral expenses A claimant under the age f 18 wh must be assisted by a parent r legal guardian WHAT CAN YOU EXPECT TO CLAIM FOR FOLLOWING A ROAD ACCIDENT? Medical expenses (past and future) Funeral expenses Lss f earnings r incme if a persn is disabled (past and future) Lss f supprt fr a dependent f a deceased victim (breadwinner, past and future) General damages fr pain, suffering and disfigurement in the case f Bdily Injury (as determined after examining the extent and severity f the injury) WHO DO ADMED MEMBERS CONTACT TO LODGE A CLAIM? Members will be required t cntact RadCver direct, as fllws: Telephne / 0860 RCOVER Website -