Unison Brokers (Pty) Ltd FSP Name, Our Street Address, Suburb, Town, Tel: +27 11 555 3000 Fax: +27 11 555 2046 Cell: 082 888 0000 Registration number: 1991/012692/07 Facsimile E-mail Personal Consultation To: Mrs C Somebody From: Name Surname Date: 30/03/2011 Fax number: 011 555 0001 Reference: SomebodyC.2011.03.30Ref0050 Email: somebody@gmail.com Medical Scheme Quotation Dear Mrs C Somebody We have pleasure in submitting a Medical Scheme quotation to you, as discussed. A comparative benefit and contribution summary of the Scheme Options is enclosed to assist you in making an informed selection between the various products. For your convenience, the products are compared horizontally in accordance with 58 criteria, resorting under Hospital benefits, Chronic benefits, Day-today benefits, Financial and Demogaphic details, and Contributions. Your contributions for the products compared are summarised below. Current Option Medical Scheme Compcare Wellness Medical Scheme Momentum Health Medical Scheme Liberty Medical Scheme Discovery Medical Scheme Option Pinnacle - 2011 Extender - Any/Any - 2011 Platinum Complete - 2011 Classic Comprehensive - 2011 Risk Contribution 6822 5624 6179 4837 Savings Contribution 1704 1876 1089 1610 Loyalty Programme 0 0 0 0 Late Joiner Penalty 1017 819 880.5 898.5 Sub Total 9543 8319 8148.5 7345.5 Annual Savings 20448 22512 13068 19320 Pro-Rated Savings 17040 18760 10890 16100 Consultation Fee 0 0 0 0 Total Contribution 9543 8319 8148.5 7345.5 Member Contribution 9543 8319 8148.5 7345.5 If a specific Scheme and Option is recommended, the reason(s) for the recommendation is(are) as follows: Affordability - Contribution reduction requested by client Affordability - Similar benefits at lower contributions Suitability of In-hospital benefits Suitability of Chronic Benefits for client needs Suitability of Day-to-day benefits for client needs Suitability of product structure for client needs Administration efficiency Scheme financial position, size or reserves Income tax benefits Geographic location of service providers Compulsory Scheme due to employer policy In hospital Benefit medical reimbursement rate For your convenience, the following documentation is also included: 1. 2011 Momentum Extender Option Info.pdf 4. 2. 2011 - Momentum Individual Application Form.pdf 5. 3. Momentum - Broker Appointment Form.pdf 6. Additional information comes here. Yours truly Name Surname Director B Comm (BR 1234)
Benefits Pinnacle - 2011 Extender - Any/Any - 2011 Platinum Complete - 2011 Plan Type New Generation with Threshold New Generation with Threshold New Generation with Threshold Plan Operation - Hospitalisation 100% of Agreed Tariff, 200% Specialist cover 100% of Scheme Tariff. 200% specialist cover 100% - 200% of Scheme negotiated Tariff - Day-to-day MSA, AFB (Annual Flexi Benefit) and ATB MSA and ATB + optional Health Saver Medical Savings Account and Above Threshold Benefit Overall Annual Maximum Unlimited Unlimited Unlimited Hospital Benefit 1 Private Hospital Care Any Private Hospital Any Private Hospital Any Private Hospital 2 Co-payment on admission Certain procedures, Endoscopies and Scans ne ne 3 Oncology Unlimited R450 000 p/b/p/a - 20% co-payment thereafter Unlimited at DSP (ICON), Specialised drug limit R170 000 p/b (10% co-pay) 4 Organ Transplants Limited to PMB conditions Unlimited, R25 400 donor cover if recipient a member 200% of Scheme rate, Unlimited 5 Dialysis Limited to PMB conditions Unlimited 200% of Scheme rate, R320 000 p/b limit 6 Maternity - Natural Birth Limited to 3 days and 2 nights Unlimited Unlimited - Elective Ceasarean Limited to 4 days and 3 nights Unlimited Unlimited 7 To take home medication Limited to 7 days supply per event Limited to 7 days supply per event Limited to 7 days supply and R1500 per event 8 Psychiatric Hospitalisation Limited to 21 days per family R23 100 p/b. Max 21 days for alcohol & drug rehab 200% of Scheme rate, R19 600 p/f Radiology/Pathology/Prosthesis 1 Basic Radiology Unlimited Unlimited Unlimited 2 MRI, CT & PET Scans Unlimited, first R2 000 paid from available savings Unlimited, subject to R1600 co-payment Limited to R30 800 per family 3 Pathology Unlimited Unlimited Unlimited 4 Internal Prosthesis Protocols and various limits apply Limit: R45 000 p/b, R105 000 for cochlear implants Unlimited, sub-limits apply per prosthetic type 5 External Prosthesis Protocols and various limits apply Limited to R14 700 per family Subject to MSA and ATB - R13 800 limit p/f Sub Acute Facilities 1 Hospice Unlimited R31 800 per family Limited to R13 100 per beneficiary 2 Nursing Limited to 60 days per family Combined with Hospice benefit 200% of Scheme Rate, Limited to R19 600 per family 3 Ambulance Services Unlimited Unlimited - Netcare 911 Unlimited - ER 24 Chronic Benefit 27 CDL chronic conditions Unlimited - Any Provider but Formulary applies Unlimited - Any provider Unlimited - Any Provider but Formulary applies Additional chronic conditions Day-to-day Benefit M R8 000, M1+ R12 000. Initially paid from MSA and AFB Limited to R6 300 per family - 36 Conditions M R10 700, M1 R13 200, M2 R15 800, M3+ R18 200 - R10 700 p/b sublimit, 28 conditions Overall Annual Maximum Available Savings and Above Threshold Benefit Available Savings and Above Threshold Benefit Available Savings and Above Threshold Benefit Preferred Provider Any GP, Specialist Any GP, Pharmacist Any GP, Specialist Medical Savings Account 20%(Member)+5%(Scheme) - PM: R9806, AD: R7646, C: R2704 25% - PM: R8220, AD: R6552, C: R2580 PM: R5016, AD: R3720, C: R1440 Annual Threshold PM: R11 112, AD: R8 664, C: R3 066 PM: R9600, AD: R8400, C: R2700 PM: R6664, AD: R4958, C: R1920 Self Payment Gap PM: R1306, AD: R1018, C: R362 PM: R1380, AD: R1848, C: R120 PM: R1648, AD: R1238, C: R480 Above Threshold Benefit Various limits per service category Various limits per service category Various limits per service category GP's and medication 1 General Practitioners Subject to MSA and ATB - unlimited in ATB Subject to MSA and ATB - unlimited in ATB Subject to MSA and ATB - unlimited in ATB 2 Specialists 200% - Subject to MSA and ATB. ATB limit: R3000 p/f Subject to MSA and ATB - unlimited in ATB Subject to MSA and ATB - unlimited in ATB 3 Prescribed Medication Subject to MSA and ATB. ATB limit: R2500 p/f MSA & ATB: Single R10 800, Family R20 400 100% - Single R6130, Family R12 350 4 Pharmacy Advised Medicine R150 per script, limited to: Single R700, Family R1000 Subject to available MSA. accumulation Combined with Prescribed - no accumulation Radiology & Pathology 1 Basic Radiology Subject to MSA and ATB - Unlimited Subject to MSA and ATB - Unlimited Subject to MSA and ATB - unlimited in ATB 2 MRI, CT & PET Scans Combined with In-hospital limit Combined with In-hospital benefit Paid from Risk: Limit: 3 scans p/b 3 Pathology Subject to MSA and ATB - Unlimited Subject to MSA and ATB - Unlimited Subject to MSA and ATB - unlimited in ATB Dental Benefit 1 Conservative Dentistry Subject to MSA and ATB - Unlimited Subject to MSA and ATB - Unlimited Subject to MSA and ATB - unlimited in ATB 2 Specialised Dentistry Subject to MSA and ATB - R10 000 p/b MSA & ATB: Single R8 300, Family R21 600 Single R8500, Family R13 000 Optical Benefit 1 Examination Subject to MSA and ATB - R3 000 p/b Limited to R2600 per person per annum Single: R2 850, Family: R7 250 2 Lenses Combined with Examination benefit Combined with Examination benefit Combined with Examination benefit 3 Frames Combined with Examination benefit Combined with Examination: Frame sublimit of R1400 Frames sublimt of R1 120 per beneficiary p/a 4 Contact Lenses Combined with Examination benefit Combined with Examination benefit Combined with Examination benefit Auxilliary Services 1 Physiotherapy Subject to MSA and ATB - R5000 limit p/f Subject to MSA and ATB - Unlimited Single: R8 740, Family: R14 700 2 Psychiatry Combined with Physiotherapy limit R 12 300 per member family Subject to Physiotherapy limit 3 Psychology Combined with Physiotherapy limit Combined with Psychiatry benefit limit Subject to Physiotherapy limit HIV / AIDS R3000 limit, unless registered on program ARV treatment: Unlimited, Hospital: R44 500 p/f Unlimited, subject to registration Financial & Demographic 1 Date of information 31-Dec-08 31-Dec-09 31-Dec-09 2 Principal Members Scheme - 13 353 This Option - 762 Scheme - 81 645 This Option - 165 Scheme - 44 985 This Option - 7 971 3 Administrator Universal Administrators (Pty) Ltd Momentum Medical Scheme Administrators (Pty) Ltd V Medical Aid Administrators (Pty) Ltd 4 Scheme (Option) age profile Av. age- 36.9(41.2); Pensioner %- 11.5%(11%) Av. age- 33.2(35.1); Pensioner %- 7.6%(9.6%) Av. age- 36.8(40.5); Pensioner %- 10.8%(15.5%) 5 Solvency ratio 27.90% 15.80% 19.50% 6 Past Increases 2008-16.7%, 2009-15.5%, 2010-15%, 2011-% 2008-13.5%, 2009-14.3%, 2010-11.6%, 2011-7.9% 2008-10.9%,2009-12.9%,2010-10.4%, 2011-12.8% Contributions Salary Brackets All - - - - All - - - - All - - - - Principal Member 3264 - - - - 2739 - - - - 2790 - - - - Principal Member + Spouse 5808 - - - - 4923 - - - - 4862 - - - - Principal + Spouse + 1 child 6714 - - - - 5782 - - - - 5664 - - - - Principal + Spouse + 2 children 7620 - - - - 6641 - - - - 6466 - - - - Principal + Spouse + 3 children 8526 - - - - 7500 - - - - 7268 - - - - E&OE. Errors and omissions excepted. [Mrs C Somebody]
Benefits Classic Comprehensive - 2011 Plan Type New Generation with Threshold Plan Operation - Hospitalisation 100% of Scheme Tariff/ Specialist cover included - Day-to-day Medical Savings Account and Above Threshold Benefit Overall Annual Maximum 100% of Scheme tariff - Unlimited Hospital Benefit 1 Private Hospital Care Any Private Hospital 2 Co-payment on admission Certain procedures, Endoscopies and Scans 3 Oncology R400 000 over 12 mth cycle -80% of cost thereafter 4 Organ Transplants Unlimited 5 Dialysis Unlimited 6 Maternity - Natural Birth Limited to 3 days and 2 nights - Elective Ceasarean Limited to 4 days and 3 nights 7 To take home medication Subject to Acute Medicine benefit 8 Psychiatric Hospitalisation Limited to 21 days per beneficiary Radiology/Pathology/Prosthesis 1 Basic Radiology Unlimited 2 MRI, CT & PET Scans Unlimited. R2100 for conservative back/neck from MSA/ATB 3 Pathology Unlimited 4 Internal Prosthesis Certain limits apply 5 External Prosthesis t known Sub Acute Facilities 1 Hospice t known 2 Nursing Combined with Hospice benefit 3 Ambulance Services Unlimited - Netcare 911 Chronic Benefit 27 CDL chronic conditions Unlimited - Any Provider but Formulary applies Additional chronic conditions Unlimited - 33 Conditions Day-to-day Benefit Overall Annual Maximum ne Preferred Provider Any GP, Specialist Medical Savings Account 25% - PM: R7596, AD: R7188, C: R1512 Annual Threshold PM: R8450, AD: R8450, C: R1600 Self Payment Gap PM: R845, AD: R1262, C: R88 Above Threshold Benefit Various limits per service category GP's and medication 1 General Practitioners Subject to MSA and ATB - unlimited in ATB 2 Specialists Subject to MSA and ATB - unlimited in ATB 3 Prescribed Medication 75%/100% - M R16 900, M1 R19 850, M2 R23 050, M3+ R26 300 4 Pharmacy Advised Medicine Subject to available MSA Radiology & Pathology 1 Basic Radiology Subject to MSA and ATB - Unlimited 2 MRI, CT & PET Scans Subject to MSA(first R2 100) and Hospital Benefit 3 Pathology Subject to MSA and ATB - Unlimited Dental Benefit 1 Conservative Dentistry Subject to MSA and ATB - R16 000 limit p/b 2 Specialised Dentistry Combined with Conservative Dentistry benefit Optical Benefit 1 Examination Subject to MSA and ATB - R2 800 limit p/b 2 Lenses Included in Examination benefit 3 Frames Included in Examination benefit 4 Contact Lenses Included in Examination benefit Auxilliary Services 1 Physiotherapy Subject to MSA and ATB - Unlimited 2 Psychiatry Subject to MSA and ATB - R16 200 limit per family 3 Psychology Combined with Psychiatry benefit limit HIV / AIDS Unlimited, subject to registration on HIVCare Financial & Demographic 1 Date of information 31-Dec-09 2 Principal Members Scheme - 917 580 This Option - 179 405 3 Administrator Discovery Health (Pty) Ltd 4 Scheme (Option) age profile Av. age- 31.6(35.1); Pensioner %- 5.9%(8.7%) 5 Solvency ratio 25.50% 6 Past Increases 2008-9.8%, 2009-12.8%, 2010-9.8%, 2011-7.9% Contributions Salary Brackets All - - - - Principal Member 2533 - - - - Principal Member + Spouse 4929 - - - - Principal + Spouse + 1 child 5435 - - - - Principal + Spouse + 2 children 5941 - - - - Principal + Spouse + 3 children 6447 - - - - E&OE. Errors and omissions excepted. [Mrs C Somebody]
STATUTORY NOTICE Provider and Representative disclosures in terms of the Financial Advisory and Intermediary Services Act,. 37 of 2002 (FAIS Act) The FAIS Act was enacted for your benefit. Unison Brokers (Pty) Ltd is an approved Financial Services Provider (FSP). Please note that this disclosure does not form part of the insurance contract with the service providers we are contracted to. As a long-term or short-term insurance policyholder, or prospective policyholder, you have the right to the following information: 1. The Financial Service Provider Unison Brokers (Pty) Ltd was established in 1991, Registration Number 1991/012692/07. As a licensed Financial Service Provider (FSP) in terms of the FAIS Act, Unison Brokers (Pty) Ltd accepts responsibility for the actions of its representatives acting within their mandates in rendering services as defined by the FAIS Act and Codes of Conduct promulgated in terms of the Act. Company Name Capacity Council for Medical Schemes Accreditation Number Financial Services Board Accreditation Number Office Address Postal Address Unison Brokers (Pty) Ltd Independent Intermediary BR 2593 12345 FSP Name, Our Street Address, Suburb, Town PO Box 0000, Suburb, Code, Telephone +27 11 555 3000 Fax +27 11 555 2046 E-mail Website 2. The Representative admin@unison.co.za http://www.unison.co.za Our representatives meet the fit and proper requirements as prescribed by the FAIS legislation. In terms of serving this notice, the FSP is represented by the following Representative: Name Capacity Council for Medical Schemes Accreditation Number Assisted by: (In case of Apprentice Brokers only) Office Address Postal Address Name Surname Key individual BR 1234 FSP Name, Our Street Address, Suburb, Town PO Box 0000, Suburb, Code, Telephone +27 11 555 3000 Fax +27 11 555 2046 Cellular 082 888 0000 E-mail 3. Financial Services Product Categories admin@unison.co.za As an authorised FSP we are licensed to render intermediary services in respect of the following financial Product Categories: Health Service Benefits, Long Term Insurance, Category A (e.g. Funeral Policies), Long Term Insurance, Category B (e.g. Life Policies), Pension Benefits, Securities and Investments, Forex Investment, Short Term Deposits, Friendly Society Benefits, 4. Insurance Product Providers We are contracted with the following Insurance Companies: Santam, Liberty, First Rand, Discovery Life, 5. Medical Scheme Product Providers We are contracted with the following Medical Schemes: Bestmed Medical Scheme, Bonitas Medical Scheme, Compcare Wellness Medical Scheme, Discovery Medical Scheme, Fedhealth Medical Scheme, Hosmed Medical Scheme, Liberty Medical Scheme, Medihelp Medical Scheme, Medshield Medical Scheme, Momentum Health Medical Scheme, Pro Sano Medical Scheme, Profmed Medical Scheme, Resolution Health Medical Scheme, Selfmed Medical Scheme, Sizwe Medical Scheme, Spectramed Medical Scheme, Topmed Medical Scheme, 6. Indemnity cover held, Amount: 1,000,000.00, Insurer: Insurance Company 7. Shareholding of more than 10% in any Insurer none 8. Remuneration of more than 30% from any Medical Scheme Name of Medical Schemes from which the FSP received more than 30% of total remuneration during the past calendar year (if any) none 9. Compliance related queries For any compliance matter relating to FAIS or the Policyholder Protection Rules you may contact our Compliance Officer. Please put any complaint in writing and address it to any of the following: Internal External Name Name, Surname Name Surname Company Unison Brokers (Pty) Ltd Compliance Company Postal address PO Box 0000 Suburb Johannesburg PO Box 12345, Suburb Johannesburg Telephone 011 000 0000 011 999 0000 Facsimile 011 000 0000 011 999 9090 E-mail compliance@unison.co.za compliance@company.co.za If the matter is not resolved to your satisfaction, you may address your queries to the FAIS Ombud. Ms luntu Bam FAIS Ombud Telephone 0860 324 766 PO Box 74571 Fax 012 348 3447 Lynnwood Ridge E-mail info@faisombud.co.za 0210 10. Your rights 10.1 Your right to know the impact of the decision you elect to make: The representative or insurer dealing with you must inform you of: The premium you may be paying and the nature and extent of the benefits you may receive. The possible impact of this purchase on your finances. The possible impact of this purchase on your other policies (affordability). The contract terms of the product you intend to purchase. 10.2 Your right when being advised to replace an existing policy You may not be advised to cancel a policy to enable you to purchase a new policy or amend an existing policy, unless: The intermediary identifies the policy as a replacement policy. The implications of the cancellation of the policy are disclosed to you, such as: The influence on your benefits under the policy to be replaced. The additional costs incurred with the replacement. The insurer or medical scheme which issued the original policy may contact you to discuss the matter with their representative. 10.3 Your right to be informed by the insurer / medical scheme The medical scheme / insurer will forward you documentation confirming policy or member details, which may also include: The name of the insurer / medical scheme The product(s) being purchased The cost in Rands of the transaction and specifically: Waiting periods, if any Loadings, if any Late Joiner Penalties, if any Exclusions, if any The amount of commission and other remuneration being paid to the intermediary, Contact number and address of compliance officers of the insurer or product provider. Waiting periods, if any In the case of policies in an investment element, the ongoing expense and any other fees and charges payable.
10.4 Your right to cancel the transaction In most cases you have the right to cancel a policy in writing within 30 days after receipt of the documentation from the insurer or medical scheme. Please bear in mind that you may not exercise this right if you have already claimed under the policy. 10.5 Other important issues It is important that you are sure that the product or transaction meets your needs and that you feel you have all the information you need before making a decision. It is recommended that you discuss with the intermediary, medical scheme or insurer the possible impact of the proposed transaction on your finances, your other policies or your broader insurance portfolio. Where paper forms are required, it is advisable to sign them once they are fully completed. Feel free to make notes regarding verbal information, and to ask for written confirmation or copies of documents. During any client contact the representative has to explain the aim and intention of the contact to you. In cases where a financial service was delivered to you orally you may request written confirmation The representative of the company may not request or induce the client in any manner to waive any right or benefit conferred on the client by or in terms of any provision of the FAIS General Code of Conduct. The company undertakes to reveal any conflict or possible conflict in interest in terms of any advice or interaction with you. 11. Your obligations With the completion and submission of any transactional requirement(s): 12. Disclaimer You have to ensure, in those instances where the representative completes any transactional requirement(s) on your behalf, that the information is accurate and complete, You have to reveal all material facts accurately and comprehensively, You have to be aware of the possible consequences of misrepresentation, withholding facts or presenting incorrect information. The information attached to this quotation, and in particular the benefit comparison, consists of a key benefit and financial and demographic summary of the scheme options only and does not replace the benefits contained in the Rules of the schemes summarised as such. r does it propose to be a comprehensive or factually correct listing of the benefits or all the benefits of the various products and in all instances the Rules of the Schemes shall prevail in case of any discrepancy.. Although care has been taken to represent the benefits and limitations of the products accurately, no liability is accepted for any incorrect information or any decision taken on the strength of the information given. 13. Remuneration Should you be an existing client or appoint our company as your Intermediary, a monthly ongoing fee is payable by the Medical Scheme to the FSP. This fee is legislated and is determined by the Department of Health from time to time and is currently limited to 3% of the total monthly contribution or R60.70 plus VAT, whichever is the lesser. I hereby acknowledge that I understand the contents of this notice. Client Name Signature Date GLOSSARY OF TERMS AND ABBREVIATIONS NHRPL National Health Reference Price List The tariff and applicable rules for specific services or supplies provided, based on the 2006 NHRP List published by the Council for Medical Schemes, with annual inflationary increases determined by the Department of Health. SPG Self-Payment Gap A period during which a member will be required to fund a certain portion of day-to-day claims from his/her own pocket after the Medical Savings Account is depleted and when the Option has an Above Threshold Benefit. MSA PP/DSP PMB CDL LJP Medical Savings Account A savings facility attached to certain Scheme Options to which members contribute monthly, which is limited to a maximum of 25% of total monthly contributions. rmally a credit equal to 12x the monthly savings contribution is available upfront. Preferred Provider/Designated Service Provider A service provider with whom the Scheme has negotiated preferential rates, or who is part of a preferred provider network. Prescribed Minimum Benefits A list of 270 conditions or group of conditions and 28 chronic illness conditions as listed in Annexure A of the Medical Schemes Act for which any Scheme is obliged to provide members certain minimum benefits in the form of diagnosis, treatments and services. Chronic Disease List A specified list of 28 chronic conditions forming part of the Prescribed Minimum Benefits in respect of which all schemes are obliged to cover in full according to the specific Scheme or Option treatment plans and protocols. Late Joiner Penalty A contribution loading imposed on persons older than 35 who were not members or dependants of a medical scheme from a date before 1 April 2001. The loading is based on the Risk portion of the contribution and is calculated according to the years without cover after the age of 35, with credit given for years of cover after the age of 21, according to the following scales: 1-4 years - 5% 5-14 years - 25% 15-24 years - 50% 25+ years - 75%. OAL ATB Major Medical benefits Formulary General Waiting Period Conditionspecific Waiting Period Overall Annual Limit An upper limit, normally expressed as a Rand amount, to which claims are restricted during a benefit year for Hospital claims only or all claims incurred by the member and paid by the Scheme. Above Threshold Benefit A benefit forming part of certain Scheme Options that provides continued cover for day-to-day claims and accessed after depletion of a members' MSA, together with reaching a specified Threshold in accumulated legitimate claims, expressed as a Rand amount. Inured benefits for services other than day-to-day benefits, such as hospitalsation and the treatment/procedures performed whilst a beneficiary is hospitalised. A defined list of medicine used in the treatment of various diseases. A period in which a Beneficiary is not entitled to claim any benefits. A general waiting period of 3 months will usually be applicable if a member was not previously a member of a registered medical scheme, or was a member of a medical scheme for more than two years and the change of medical scheme was not as a result of a change of employment, or if the period between the termination of membership of a previous scheme and joining a new scheme is more than ninety days. 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 within the twelve (12) month period ending on the date on which an application for membership was made. A 12 month condition-specific waiting period will usually be applicable if a member was not previously a member of a registered medical scheme, or was a member of a medical scheme for less than two years and the change of medical scheme was not as a result of a change of employment, or if the period between the termination of membership of a previous scheme and joining a new scheme was more than ninety days.
Focus on the Extender Option The Extender Option is designed for members who require unlimited private hospitalisation, as well as extensive chronic cover and day-to-day benefits. Members have the flexibility to choose their in- and out-of-hospital providers this choice determines the contribution payable. Major Medical Benefit (In-hospital benefit) Provider: Limit: Rate: Specialised Procedures: Co-payment: MHR = Momentum Health Rate Any hospital or Associated hospitals Unlimited Associated specialists covered in full Other specialists covered up to 200% of MHR Hospital accounts are covered in full at negotiated rate 50 Procedures covered Payable if applicable per specialist for 17 referral procedures. See benefit table below for more Chronic and Day-to-day benefit (Out-of-hospital benefit) Chronic provider: Chronic conditions covered: Day-to-day provider: Savings: Any provider: reference priced formulary, or Associated GP & Courier pharmacies: entry-level formulary, or State: entry-level formulary Cover for 62 conditions: Unlimited cover for 26 conditions, according to CDL in PMBs Cover for 36 additional conditions limited to R6 300 per family per year Any, Associated or State Fixed at 25% of total contribution Threshold: R9 600 for the principal member R8 400 per adult dependant R2 700 per child (maximum of three) CDL = Chronic Disease List; PMB = Prescribed Minimum Benefits The Health Platform Provider: Any or Associated Momentum Health 2011
Major Medical Benefit (In-hospital benefit) Momentum Health s in-hospital or Major Medical Benefit provides cover for 50 Specialised Procedures as well as unlimited cover for hospitalisation. Associated specialists are covered in full, while other specialists are covered up to 200% of MHR. Hospital accounts are covered in full at the negotiated rate, provided that treatment has been authorised. Under the hospitalisation benefit, hospital accounts and related costs incurred in hospital (from admission to discharge) are covered provided that treatment has been authorised. Specialised Procedures do not necessarily require admission to hospital and are included in the Major Medical Benefit provided that the treatment is clinically appropriate and has been authorised. If authorisation is not obtained, a 30% co-payment will apply on all accounts related to the event, provided authorisation would have been granted according to the rules of the Scheme. In the case of an emergency, you or someone in your family or a friend may obtain authorisation within 72 hours of admittance. If you choose Associated hospitals and you do not use this provider, a 30% co-payment will apply on the hospital account. The Chronic Benefit (Out-of-hospital benefit) The Chronic Benefit covers certain serious and life-threatening ailments that need ongoing intervention. On the Extender Option, you may choose Any, Associated or State as your Chronic Benefit delivery model. Chronic cover is unlimited for 26 conditions according to the Chronic Disease List (CDL), which forms part of the Prescribed Minimum Benefits (PMBs). A limit of R6 300 per family per year applies to an additional 36 conditions. Chronic benefits are subject to registration and approval. The Day-to-day Benefit (Out-of-hospital benefit) The Day-to-day Benefit covers expenses incurred out-of-hospital. The level of Savings is fixed at 25% of total contribution. This is below the Threshold level and will result in a self-funding gap. Although accumulation to Threshold is at 100% of MHR, you may claim a higher amount from Savings, thus resulting in a bigger self-funding gap. Once you reach the Threshold, your claims are paid at 100% of MHR from Extended Cover. Annual benefit sub-limits apply before and after the Threshold. If you have selected Any or State as your out-of-hospital provider, any GP may be consulted. If you have selected Associated as your out-of-hospital provider, an Associated GP must be consulted. If not, claims will only accumulate at 70% of MHR before Threshold, and a 30% co-payment will apply once in Extended Cover. Momentum Health 2011
The Health Platform Benefit The Health Platform Benefit is available to all Momentum Health members, is paid from the risk benefit and does not deplete your day-to-day cover (subject to prenotification). This unique benefit encourages health awareness, enhances the quality of life and gives peace of mind through: preventative care early detection maternity programme management of certain diseases health education and advice local and international emergency cover The Momentum HealthReturns programme Momentum Health believes that we should not only support you in times of illness, but should actively assist you with preventing illness and detecting it as early as possible. In as few as two easy steps, you can earn up to R3 600 (R1 800 x 2) in cash from Momentum. The first step towards earning HealthReturns is to undergo a free Health Assessment. These can be done at Clicks Dis-Chem, Atlas, Sparkport, Umhlatuze, Tzaneng and Pelican pharmacies, and the results remain valid for 12 months from the date of assessment. You qualify for one free Health Assessment per year as part of your Health Platform benefit. The Scheme will inform you of the general status of your health, based on the latest Health Assessment results received. In the small number of cases where the results of the Health Assessment show elevated risk levels, Momentum Health may recommend further investigation by your treating doctor. Thereafter, you may be advised to register on a Chronic Disease Management Programme and to fully adhere to prescribed treatment protocols. For the majority of members, once they have been for their Health Assessment, the only step that remains is to be active. Momentum assesses your activity levels according to either: the outcome of a fitness assessment completed at a Virgin Life Care or Wellness Coaching Network facility (fitness assessment can be paid from Health Saver) your pedometer steps, if you own a Momentum pedometer and download your steps to the pedometer community (pedometer can also be paid from Health Saver) your gym visits, provided you belong to Virgin Active or Planet Fitness through Multiply, Momentum s wellness programme If you have Multiply membership, own a Momentum pedometer, have completed the appropriate fitness assessment and belong to an appropriate gym through Multiply, your HealthReturns will be calculated on the highest of the three results. But not only do you get three options for earning HealthReturns, Multiply members who are on the top two activity levels will receive double the HealthReturns! A monthly SMS will be sent to you, indicating the amount you will be receiving for that given month. Actual payment of the HealthReturns will take place quarterly. Momentum Health 2011
Benefit schedule Major Medical Benefit General rule Provider Overall limit Co-payment for 17 referral procedures Associated specialists covered in full, other specialists covered up to 200% of MHR. Hospital accounts are covered in full at negotiated rate. Subject to authorisation, management programmes, clinical protocols and Scheme Rules. Sub-limits apply per year unless stated otherwise Any hospital or Associated hospitals ne Referred by an t referred by an appropriate GP** appropriate GP** Procedures performed while admitted to hospital (inhospital) Procedures performed in- or out-of-hospital **Appropriate GP referral Arthroscopy; Carpal Tunnel Syndrome; Back and neck surgery; Functional nasal and sinus procedures, Joint replacements; Laparoscopy and Nissen fundoplication; Colonoscopy; Back and neck treatment; Cystourethroscopy; Treatment for disease of the conjunctiva, Gastroscopy; Nail surgery; Treatment relating to skin lesions; Sigmoidoscopy; Treatment of headaches; Treatment of Adult Influenza and Adult respiratory tract infections R850 co-payment co-payment if performed out-ofhospital R850 co-payment if done in-hospital R1 350 co-payment R500 co-payment if done out-of-hospital R1 350 co-payment if done in-hospital Members may obtain a specialist referral from Any GP if they choose Any or State for out-of-hospital provider Members must obtain a specialist referral from an Associated GP if they choose the Associated out-of-hospital provider Hospitalisation Consultations and visits High and intensive care Casualty or after-hour visits Dialysis Oncology Newly diagnosed members who selected State as their out-of-hospital provider must obtain their treatment from an authorised oncologist Organ transplants (recipient) Organ transplants (donor) Only covered when the recipient is a member of the Scheme In-hospital dentistry - maxillo-facial surgery and impacted wisdom teeth - general anaesthesia for children under 7 Maternity confinements Neonatal intensive care MRI and CT scans (in- and out-of-hospital) Associated specialists covered in full Other specialists covered up to 200% of MHR Unlimited Subject to Day-to-day Benefit Unlimited Limited to R450 000 per beneficiary per year, thereafter a 20% co-payment applies Unlimited R12 700 cadaver costs R25 400 live donor costs (incl. transportation) Hospital and anaesthetist accounts paid from Major Medical Benefit, subject to R1 200 copayment. Dental, dental specialist and maxillofacial surgeon accounts paid from Day-to-day Benefit and accumulate towards limit Unlimited Unlimited Unlimited, subject to R1 600 co-payment per scan Momentum Health 2011
Medical and surgical appliances in-hospital (support stockings, knee and back braces etc.) Prosthesis internal (incl. knee and hip replacements, permanent pacemakers etc) Prosthesis external (artificial arms, legs etc) Mental health - psychiatry and psychology - drug and alcohol rehabilitation Take-home medicines Rehabilitation, private nursing, Hospice and step-down facilities Immune deficiency related to HIV infection - Anti-retroviral treatment - In-hospital Aids cases Specialised Procedures Chronic Benefit R4 050 per family Cochlear implants: R105 000 per beneficiary, maximum 1 event per year Intraocular lenses: R4 500 per beneficiary per event, maximum 2 events per year Other internal prostheses: R45 000 per beneficiary per event, maximum 2 events per year R14 700 per family Annual limit for mental health of R23 100 per beneficiary, 21-day sub-limit applies to drug and alcohol rehabilitation, subject to treatment at preferred provider 7 days supply R31 800 per family At preferred provider Unlimited R44 500 per family 50 Specialised Procedures covered (when clinically appropriate) in- and out-of-hospital General rule Benefits are subject to registration and approval Provider Any, Associated or State*** Cover 62 conditions, including CDL in PMBs Unlimited for 26 conditions according to CDL in PMBs Limit Limited to R6 300 per family p.a. for 36 additional conditions ***If the State cannot provide you with the chronic medicine you need for a chronic condition contained in the Prescribed Minimum Benefits Chronic Disease List, you may obtain your medicine from a Prime Cure clinic or Prime Cure doctor, subject to a formulary and Scheme approval. Day-to-day Benefit General rule Provider Acupuncture, Homeopathy, Naturopathy, Herbology, Audiology, Occupational and Speech therapy, Chiropractors, Dieticians, Biokinetics, Orthoptists, Osteopathy, Audiometry, Chiropody, Podiatry, Physiotherapy and Social workers Mental health (incl. psychiatry and psychology) Dentistry basic Benefits are first paid from Savings and then from Extended Cover. Claims accumulate to the Threshold and are reimbursed from Extended Cover at 100% of MHR. You will be liable for payment of certain claims before Extended Cover is activated. This is known as the self-funding gap. Annual benefit sub-limits apply before and after the Threshold Any, Associated or State Unlimited R12 300 per family Unlimited Momentum Health 2011
Dentistry specialised External medical and surgical appliances (incl. hearing aids, glucometers, blood pressure monitors, wheelchairs etc.) General practitioners Specialists Optical and optometry Pathology and radiology Prescribed medication Over-the-counter medication (incl. prescribed vitamins) R8 300 per beneficiary, R21 600 per family. Both in- and out-of-hospital dental specialist accounts accumulate towards the limit R15 000 per family Subject to a R4 700 sub-limit for hearing aids Depending on the out-of-hospital provider selected Any or State providers: Unlimited Associated providers: 100% of MHR for Associated GPs, 70% of MHR for non-associated GPs Unlimited Overall limit of R2 600 per beneficiary, frame sublimit of R1 400 Unlimited (MRI and CT scans covered from Major Medical Benefit) R10 800 per beneficiary, R20 400 per family Subject to Savings, does not accumulate towards Threshold Health Platform General rule The benefits listed in this schedule are paid from the Health Platform, subject to pre-notification What is the benefit? Who is eligible? How often? Preventative care Baby immunisations Children up to age 6 As required by the Flu vaccines Beneficiaries under 18 Beneficiaries 60 and older High-risk beneficiaries Department of Health Once a year Tetanus diphtheria injection All beneficiaries As needed Pneumococcal vaccine Beneficiaries 60 and older As needed High-risk beneficiaries Early detection tests Dental examination (incl. sterile tray and gloves) Pap smear (pathologist) Consultation (GP*or gynaecologist) All beneficiaries Women 15 and older Once a year Once a year Mammogram Women 40 and older Once every 2 years DEXA bone density scan (radiologist, GP* or specialist) Beneficiaries 50 and older General physical examination (GP)* Beneficiaries between 21 and 29 Beneficiaries between 30 and 59 Beneficiaries between 60 and 69 Beneficiaries 70 and older Once every 3 years Once every 5 years Once every 3 years Once every 2 years Once a year Prostate specific antigen (pathologist) Men between 40 and 49 Once every 5 years Health Assessment Body mass index, blood pressure test, cholesterol and blood sugar test (finger prick test) Men between 50 and 59 Men between 60 and 69 Men 70 and older All adult beneficiaries Once every 3 years Once every 2 years Once a year Once a year Momentum Health 2011
Cholesterol test (pathologist) All adult beneficiaries Once a year Only covered if Health Assessment results indicate a total cholesterol of 6 mmol/l and above Blood sugar test (pathologist) All beneficiaries Once a year Covered for all children, only covered for adult beneficiaries if results of Health Assessment indicate sugar levels of 11 mmol/l and above Glaucoma test Beneficiaries between 40 Once every 2 years and 49 Beneficiaries over 50 Once a year HIV test (pathologist) Beneficiaries 15 and older Once every 5 years Maternity programme Maternity programme (subject to registration on the Maternity Management Programme after 8 weeks of pregnancy) Antenatal visits (Midwife, GP* or Women registered on the 12 visits gynaecologist) programme Urine tests (dipstick) Women registered on the programme Included in antenatal visits Pregnancy scans Women registered on the programme 2 scans (one before 24th week and one after) Paediatrician visits Babies up to 12 months registered on the 2 visits in baby s first year programme Health management programmes Diabetes, Hypertension, HIV/Aids, Oncology, All beneficiaries registered As needed Drug and alcohol rehabilitation, Chronic renal failure, Organ transplants, Cholesterol on the appropriate programme Health line 24-hour health advice All beneficiaries As needed Emergency evacuation Emergency evacuation in South Africa by All beneficiaries In an emergency Netcare 911 or abroad by ISOS International emergency cover R5.5 million per beneficiary per 90-day journey (includes R11 000 optometry, R11 000 dentistry and R550 000 terrorism cover) All beneficiaries In an emergency A R1 100 co-payment applies per out-patient claim * If you choose the Associated out-of-hospital provider, a 30% co-payment will apply if you do not use an Associated GP for these GP consultations. Important note: This focus page summarises the benefits available on the Extender Option. Scheme Rules always take precedence and are available on request. Momentum Health 2011
Individual Application for membership Includes Health Saver, Multiply, Advice Fee and Health Waiver 2011 Important notes: Please do not resign from your current medical scheme until you have received written notification of acceptance from Momentum Health. Momentum Health will only consider membership on receipt of a fully completed application form. Please provide a copy of ID, for principal member, spouse and adult dependants. FICA requirements for Health Saver: Proof of identification and proof of residential address (complete the residential address on this application form). If this application is for groups and the company is not already listed on Momentum Health, a company application form needs to be completed as well. If this application is for Government employees, attach a copy of your latest payslip. Section 1: Personal details Principal member Title Surname Previous surname Initials First name ID/Passport number* *If passport number, please supply date of birth Y Y M M D D Country in which passport was issued Country of residence Marital status Gender: Male Female Residential address Postal code Postal address (if different) Postal code Telephone - home (code - number) Cellphone number E-mail address Please note that the email address you provide will be used when the Scheme communicates with you A mobicard will be sent to you via sms What prompted you to join Momentum Health? Financial Adviser Advertising Internet Personal Recommendation Other, please specify details Spouse or partner Title Surname Initials First name Previous surname ID/Passport number* *If passport number, please supply date of birth Country in which passport was issued Y Y M M D D Gender: Male Female Country of residence Telephone - home (code - number) Marital status Cellphone number E-mail address Dependants First name Surname if different to principal member ID number/ Passport Country in which passport was issued Date of birth Gender (M/F) Relationship to principal member 1. 2. 3. 4. 5. HEALTH0011010E 1
Section 1: Personal details (continued) To be completed for dependants over age 21 (not including spouse) Are the adult dependants financially dependent on the principal member? Name of adult dependant 1 Name of adult dependant 2 Monthly income R Monthly income R Cellphone number Cellphone number E-mail address E-mail address Name of adult dependant 3 Name of adult dependant 4 Monthly income R Monthly income R Cellphone number Cellphone number E-mail address E-mail address Section 2: Employer information n-government employees Company Name Branch name Existing group number Business telephone number (code - number) Principal member s monthly income Principal member s occupation Branch number Employee number Date of employment D D M M Y Y Y Y Government employees Name of department Persal Number* *Please attach a copy of your latest payslip Principal member s monthly income Principal member s occupation Date of employment D D M M Y Y Y Y Section 3: Business information if self-employed Company Name Registration number Nature of Business Telephone - work (code - number) Registration date Fax - work (code - number) D D _ M M _ 2 0 Y Y Cellphone number Preferred method of communication: E-mail Post E-mail address Business physical address Postal code Business postal address (if different) Postal code Section 4: Financial adviser Name Financial adviser s code Broker house code Commission ref no Commission split % 100 % Signature of financial adviser How would you like to receive your welcome pack? Mail to member Send to branch Broker to collect Other (please specify) Date D D _ M M _ 2 0 Y Y 2
Section 5: Marketing adviser Name Branch name E-mail address Telephone - work (code - number) Marketing adviser s code Section 6: Previous medical scheme information Please list previous medical scheme membership details for principal member, spouse and adult dependants separately. Name of member Name of scheme Member number Date joined Date terminated or current Are you changing your medical scheme due to a change in your employment? Have you, your spouse or any of your dependants ever had a waiting period, pre-existing condition exclusions or a late joiner penalty? If, please attach previous membership certificate (if available). Section 7: Medical details Complete Section 7.1 if you have been a member of a medical scheme registered in South Africa for at least 24-months and less than 90 days have passed since your resignation from that scheme. If not, please complete Section 7.2. Please make sure that you have completed Section 6 before completing this section SECTION 7.1 Failure to disclose pre-existing conditions could limit and/or exclude certain benefits or result in termination of your membership Have you or your dependants ever had any of the following: 7.1.1 Have you or your dependants ever suffered from diabetes, heart disease, stroke or cancer? 7.1.2. Are you or your dependants currently taking ongoing medication or reasonably expecting to take medication in the next 12 months? 7.1.3 Have you or your dependants had an operation or admission to any hospital in the last 12 months? 7.1.4 Are you or your dependants awaiting or planning any operation or admission to hospital (including pregnancy) for treatment in the next 12 months? 7.1.5 Is there any other condition or symptom, which is not detailed in any question above, for which medical advice, diagnosis, care or treatment has already been recommended or received, or could potentially result in a medical claim within the next 12 months? If you have answered no to all of the above questions, we will not apply any waiting periods and you do not have to complete Section 7.2. If you have answered yes to any of the above questions, we will apply a three-month general waiting period to all dependants included on your application form and you do not have to complete Section 7.2. SECTION 7.2 Failure to disclose pre-existing conditions could limit and/or exclude certain benefits or result in termination of your membership All questions must be answered with a or. If to any questions, please provide full details. If more space is required, please include additional pages. Have you or your dependants ever had any of the following: 7.2.1 Disorders or problems with the heart or cardiovascular system. Eg. heart murmur, high blood pressure, raised cholesterol, shortness of breath, palpitations, chest pain, angina pectoris or heart attack? 7.2.2 Respiratory or lung trouble. Eg tuberculosis, asthma, persistent cough or other breathing problems, emphysema, coughing up blood, cystic fibrosis, sinusitis or allergic rhinitis? 7.2.3 Disorders of the digestive system, stomach, gall bladder, pancreas of liver. Eg gastric or duodenal ulcer, heartburn, hiatus hernia, rectal bleeding, Crohn's disease, ulcerative colitis, irritable bowel syndrome, hepatitis, cirrhosis, liver failure, or have you ever had a gastroscopy, colonoscopy, or other special examinations? 3
Section 7: Medical details (continued) 7.2.4 Disease or disorders of the kidneys, bladder or reproductive organs. Eg abnormal urine tests, kidney stones, nephritis, prostatitis, bladder infections, or sexually transmitted disease? 7.2.5 Disorders of the nervous system or brain. Eg epilepsy, stroke, multiple sclerosis, migraine, headaches, paralysis, Parkinson's diseae, or have you or any of your dependants had or been advised to have an MRI or CT scan? 7.2.6 Mental disorders. Eg depression, anxiety, panic attacks, schizophrenia, eating disorders, ADHD, or post traumatic stress disorder? 7.2.7 Ear, nose, throat or eye disorders. Eg defective vision, cataracts, glaucoma, retinitis, disorders of the cornea, hearing loss, ear discharge, otitis media or allergies? 7.2.8 Disorders or diseases of the skin, muscles, bones, joints, limbs, spine. Eg any skin rash, arthritis, gout, fibromyalgia, any back/neck/hip/knee or other joint trouble, multiple sclerosis, any joint problems or replacements, acne, eczema or psoriasis? 7.2.9 Diabetes, sugar in urine, thyroid or other glandular or blood disorders. Eg anaemia, bleeding disorders, growth disorder, Cushing s disease or Addison's disease? 7.2.10 Cancer, a growth or tumour of any kind including moles removed (malignant/benign)? 7.2.11 Are you or any of your dependants currently undergoing, or anticipating any specialised dental/maxillo facial treatment? 7.2.12 Have you or any of your dependants had any accidents (including motor vehicle accidents) in the past 24 months? If yes, please provide details of injuries sustained? 7.2.13 Are you or any of your dependants taking ongoing medication for any condition not listed in any other question? 4
Section 7: Medical details (continued) 7.2.14 Have you or any of your dependants had any surgical procedure in the past 24 months? 7.2.15 Are you or any of your dependants awaiting or planning any operation or admission to any hospital in the next 12 months? 7.2.16 Is there any other condition or symptom, which is not detailed in any other question, for which medical advice, diagnosis, care or treatment has already been recommended or received, or could potentially result in a medical claim within the next 12 months? Questions 7.2.17 to 7.2.18 apply to female applicants 7.2.17 Gynaecological disorders. Eg abnormal pap smear or mammogram, endometriosis, ovarian cysts, fibroids, infertility, disorders of the cervix, menstrual disorders or any abnormality of pregnancy or confinement? 7.2.18 pregnant? If you or any of dependants are living with HIV/Aids and would prefer not to disclose your or their HIV-status on this form due to confidentiality, you may wait until you have received your membership number. On receipt of your membership number please call us at 0860 50 60 80, in order to notify us that you or your dependants are living with HIV/Aids. This information will be kept confidential. Please advise us within 7 days of your date of entry onto Momentum Health, failing which membership may be terminated for non-disclosure. 7.2.19 Principal member Height (without shoes), m Tobacco smoked: Type Quantity per day Mass (clothed) kg Alcohol consumed: Type Quantity per week Spouse or partner Height (without shoes), m Tobacco smoked: Type Quantity per day Mass (clothed) kg Alcohol consumed: Type Quantity per week Adult dependant 1 Height (without shoes), m Tobacco smoked: Type Quantity per day Mass (clothed) kg Alcohol consumed: Type Quantity per week Adult dependant 2 Height (without shoes), m Tobacco smoked: Type Quantity per day Mass (clothed) kg Alcohol consumed: Type Quantity per week Adult dependant 3 Height (without shoes), m Tobacco smoked: Type Quantity per day Mass (clothed) kg Alcohol consumed: Type Quantity per week Adult dependant 4 Height (without shoes), m Tobacco smoked: Type Quantity per day Mass (clothed) kg Alcohol consumed: Type Quantity per week 5
Section 7: Medical details (continued) 7.2.20 Have you taken out a life insurance policy with Momentum during the last six months? If please supply your policy number. Current doctor Name and surname Telephone - work (code - number) How long has he/she been your doctor? Current dentist Name and surname Telephone - work (code - number) How long has he/she been your dentist? Section 8: Option choice Important note: The principal member may make changes only on 1 January each year. Ingwe Option Hospital provider Chronic and Day-to-day provider Salary Ingwe Network CareCross R8 001 or more State Prime Cure R6 001 - R8 000* R3 751 - R6 000* Provider s practice number Provider s practice name Less than R3 750* * If less than R8 000, please attach a copy of your payslip Access Option Hospital provider: Access Network Chronic and Day-to-day provider Provider s practice number Provider s practice name CareCross Medicross Prime Cure Custom Option Hospital provider Chronic and Day-to-day provider Any hospital Any Associated hospitals Associated GP and Courier Pharmacies State Incentive Option Hospital provider Chronic and Day-to-day provider Savings:10% Any hospital Any Associated hospitals Associated GP and Courier Pharmacies State Extender Option Hospital provider Chronic and Day-to-day provider Savings:25% Any hospital Any Associated hospitals Associated GP and Courier Pharmacies State Pay day-to-day claims at: Accumulation rate Up to 200% of the Momentum Health Rate Summit Option Hospital provider: Any hospital Chronic and Day-to-day provider: Freedom-of-choice 6
Section 9: Banking details for payment of contributions (Please do not provide credit card details. Mometum Health is not allowed to record your credit card details) Is the contribution payer the: Section 9.1 Principal Member (complete only section 9.2) Company (as per company application form ignore sections 9.1 and 9.2) Other (complete sections 9.1 and 9.2) Title Surname /Name of company Initials First name ID/Passport number Y Y M M D D Gender: Male Female RSA ID Date of Birth Y Y Y Y M M D D Residential address Postal code Postal address (if different) Postal code Telephone - home (code - number) Cellphone number E-mail address Section 9.2 Name of account holder Name of institution Account number Account type: Current Savings Transmission Branch code Branch name Section 10: Details for contribution collection Momentum Health may debit the above account with the amount due under the contract in accordance with the Momentum Health debit order system. I / we agree to inform Momentum Health in writing of any changes that take place. I / we authorise Momentum Health to verify such account details with the financial institution. We accept that Momentum Health will debit the account on the 1st of each month or the closest working day after the 1st. If a company account is to be debited: I / we warrant that the principal member referred to in this application is an employee of our organisation. Momentum Health may bill us for the amount due for this member in the same manner as for other members that our organisation employs. Name Position in company Signature of account holder/ Authorised signatory Date D D _ M M _ 2 0 Y Y Company Stamp Section 11: Banking details for claim refunds payable to member (Please do not provide credit card details. Momentum Health is not allowed to record your credit card details) Name of account holder Name of institution Account number Account type: Current Savings Transmission Branch code Branch name Signature of principal member Date D D _ M M _ 2 0 Y Y 7
Section 12: Terms and conditions 1. I apply for my dependants and I to join Momentum Health (the Scheme) administered by Momentum Medical Scheme Administrators (MMSA) (the Administrator) and agree to familiarise myself with, and be bound by, the Rules of the Scheme (the Rules) if my application for membership is accepted. I understand that I may request to inspect the Rules and that, in the event of a dispute, the Rules will be decisive. 2. I acknowledge that if my dependants and I do not disclose all the information that is relevant to the assessment of this application, it will make any contracts to which this application relates null and void. I will also forfeit all contributions that I paid to the Scheme. In such an event the Scheme will have the right to reclaim any amounts that it may have paid to me or any person on behalf of me or my dependants under such contracts. 3. I will notify the Scheme if any alteration takes place in any circumstances on which the Scheme based its assessment of its risk after the date of this application and before the date of the Scheme s acceptance of the risk. I acknowledge that failure to do so will make any contracts to which this application relates null and void. In such event, the Scheme will have the right to reclaim any amounts that it may have paid to me or any person on my or my dependants behalf under such contracts. 4. I understand that this application form is valid for 30 days only 5. I am aware that the Scheme may ask for proof of identification at any stage. 6. It is my responsibility alone (as a member) to make sure that the Scheme receives the monthly contribution. n-receipt of a single month s contribution will result in suspension of medical scheme benefits. This suspension will last until I have paid all contributions in arrears. n-receipt of two months contributions will result in cancellation of my membership of the Scheme. 7. If the employer is responsible to pay my medical scheme contributions, I authorise and instruct my employer to: deduct from my remuneration (and any other sums due to me) any amounts that I may owe to the Scheme from time to time; and pay such amounts to the Scheme. I also authorise and instruct any person (such as my employer, a pension fund or provident fund) who holds funds for my benefit after I cease employment, to pay and continue to pay the amounts referred to in the first sentence of this clause to the Scheme as and when it is due. Furthermore, I understand that I will be liable for any legal costs that may be incurred by any party in the recovery of any amount that I owe to the Scheme. 8. I will pay all sums that I owe to the Scheme on demand. Failure to pay any debt due to the Scheme may result in suspension of membership and/or handover to a third party for debt collection. 9. The answers that I have given here are full, complete and true. I understand that if I am accepted as a member of the Scheme, my answers on this form will form the basis of my membership. 10. I realise that I must submit evidence of my own good health and that of my dependant/s to the Scheme and that the Scheme may limit or exclude benefits for any particular ailment, disease, disorder, condition or disability that has existed on my admission date. 11. If I am accepted as a member, I must, both now and in future, give the Scheme all such information and evidence as it may require from time to time. For this purpose, authorise the Scheme and/or the Administrator and/or my financial adviser to obtain from any person any necessary information that they in their sole and absolute discretion may require concerning any of my dependants or me in assessing any risk or claim in relation to this application or regarding my medical scheme membership and I direct that person to provide the Scheme and/or the Administrator and/or financial adviser with such information on request. I authorise any medical doctor or other provider who has attended me in the past or who will attend me in the future to provide the Scheme and/or the Administrator with such information as it may require. I therefore waive the provisions of any law or regulation that restricts the giving of such information. I understand that I must also submit to any examination by the Scheme s medical assessor as and when the Scheme requires this. 12. In the case of new members of the Scheme, the following may apply: A three-month general waiting period; A twelve-month exclusion on a pre-existing condition; and/or Late-joiner contribution penalty. 13. I will notify the Scheme if I or any of my dependants are living with HIV/Aids. 14. I will notify the Scheme should I or any of my dependants require hospitalisation for a non-emergency event at least 48 hours before the event. I acknowledge that failure to do so will result in a reduction of benefits payable by the Scheme for any procedure undertaken. 15. I undertake to give 30 days notice should I wish to terminate my membership. 16. I understand that if I have selected the Ingwe or Access Options, day-to-day and chronic claims will be paid only for the chosen providers. 17. I undertake to obtain the necessary consents from any of my dependants to whom these conditions may apply and hereby indemnify the Scheme and / or administrator against any claim which may arise as a result of my failure to do so. 18. Words used in this application have the meaning that the Rules give them. 19. I consent to the recording of all conversations between me and the Scheme or the Administrator, and all information obtained through these conversations will form part of the Scheme s and the Administrator s records. I also consent to all these records remaining the sole property of the Scheme and the Administrator. 20. I acknowledge that my financial adviser will have access to my membership information and that this access will stay in-force until I notify the Scheme of a change in financial adviser. Should Momentum Health confirm your start date or terms of acceptance before activation? Signed at Starting date 0 1 M M 2 0 Y Y Signature of principal member Date D D _ M M _ 2 0 Y Y The Health Saver is a free product available to all Momentum Health members. We need your consent to activate your Health Saver account. (See page 9) 8
Annexure for complementary products 2011 Important notes: Momentum Health members may add any of these complementary products. You need to complete the contract details for each product required. We will use the personal details completed for Momentum Health for this contract FICA requirements for Health Saver: Proof of identification and proof of residential address Product Selection: Please indicate which Complementary products you are applying for, complete relevant sections and sign page 13. Health Saver Multiply Advice Fee Health Waiver Section 1: Health Saver contract details Sign below if you would like Momentum to activate your free Health Saver account. You can use this account as you see fit to make provision for additional healthcare expenses Signature Complete the section below if you wish to make monthly contributions to the Health Saver. Monthly Health Saver amount R Date D D _ M M _ 2 0 Y Y and/or upfront single amount R Do you require credit *Credit not available on single upfront amounts Please note that the Health Saver credit amount is subject to a variable interest rate. Credit assessment inventory (complete if credit option was selected) Joint gross monthly household income subtotal: R Joint monthly household expenses: a) Discretionary expenses (e.g. movies, eating out ) R b) Contractual expenses (e.g. car repayments, retail accounts) R Expenses subtotal: R Net monthly income: R Credit provider information In terms of the regulations of the National Credit Act 34 of 2005, the following information must be supplied. NCR number NCR CP 173 Name of credit provider: Physical Address: Momentum Group Limited 268 West Avenue Centurion Gauteng 0157 Contact number 0860 11 78 59 Weekdays 08:00 to 17:00 9
Section 2: Multiply Contract details Contributions will be calculated based on the membership composition of Momentum Health: Single member Family of two Family of three or more How would you like to receive your welcome pack? Mail Client collect Branch Broker collect Name of previous lifestyle programme Previous lifestyle programme status (Please provide proof of status with the most recent statement not older than 1 month) Section 3: Advice Fee Contract details Please select one of the following Advice Fee options: Standard monthly amount R 55.00 R 70.00 R 85.00 Increase option Annual review ne te: If group pays for Advice Fee, amount will be as per the group amount selected. Section 4: Health Waiver Section 4.1 Insured life/lives Insured life/lives: Section 4.2 Contract details Benefit payment term: Principal member 5 years Spouse 10 years Have you smoked or used any other form of tobacco in the past twelve months? Principal member: Medical disclaimer Spouse: Have you suffered from or do you currently suffer from or take any chronic treatment for any disease for example cancer, cardiovascular, kidney disease, stroke, HIV/Aids, respiratory, neurological or connective tissue disease? Principal member: If yes, Condition/impairment Doctor s name Currently Last symptoms Fully recovered? Y Y M M Spouse: If yes, Condition/impairment Doctor s name Currently Last symptoms Fully recovered? Y Y M M Exclusion for pre-existing condition All claims arising from any physical defects, illnesses, bodily injuries or diseases that the insured life suffered from, was aware of, or has received medical treatment or advice for in the three years prior to the starting date of a qualifying benefit, are excluded for the first three years from the starting or restarting date of that benefit. If no such qualifying benefit exists, the 3-year period will apply to the starting date of this benefit. If the principal member upgrades his options under his Momentum Health membership or adds new dependants (except as a result of marriage or child birth) to his Momentum Health membership, a new 3-year period will apply to the increase in the Momentum Health contribution from the date of the increase. Signature of principal member Date D D _ M M _ 2 0 Y Y Signature of spouse Date D D _ M M _ 2 0 Y Y Section 4.3 Start of policy The starting date will depend on the starting date of your Momentum Health membership. This policy cannot have a starting date that is earlier than the Momentum Health starting date. Automatic starting date* Section 4.4 Replacement of insurance x *The starting date will be the first day of the month following the acceptance of the benefits. Do any benefits under this policy replace the whole or any part of your existing insurance with any insurer (whether replacement is to occur immediately or to replace an insurance that you discontinued within the past four months or that you will discontinue within the next four months)? 10
Section 4: Health Waiver (continued) If, the financial adviser must discuss the facts and implications with the applicant, then fill in the Replacement Policy Advice Record - MOM 681 - and attach it to this application form. Replacement of any insurance is generally to the disadvantage of the applicant because it involves duplication of the initial costs charged to the policy. Section 4.5 Policy Holder details Name of legal entity Contact person in case of legal entity Registration number Postal address Telephone - work (code - number) Registration date Fax - work (code - number) D D _ M M _ 2 0 Y Y Postal code Cellphone number Correspondence language: English Afrikaans E-mail address Preferred method of communication: E-mail Post Tax status: Tax status of trust beneficiaries if the applicant is a trust company Company / Close Corporation (M) Natural persons (N) ntaxable Institution(I) Company (C) Natural persons (P) ntaxable Institution(Z) Section 5: Contribution payer information (Please do not provide credit card details. Momentum is not allowed to record your credit card details) If different account details required per complementary product, please make a copy of the annexure and attach to this application form Is the contribution payer the: Principal Member (complete only section 5.2) Company (as per company application form ignore sections 5.1 and 5.2) Other (complete sections 5.1 and 5.2) Section 5.1 Title Surname /Name of company Initials First name ID/Passport number Y Y M M D D Gender: Male Female RSA ID Date of Birth Y Y Y Y M M D D Residential address Postal code Postal address (if different) Postal code Telephone - home (code - number) Cellphone number E-mail address Section 5.2 (Please do not provide credit card details. Momentum is not allowed to record your credit card details.) Name of account holder Name of institution Account number Account type: Current Savings Transmission Deduction date 0 1 Branch code Branch name Should Momentum group* all collections from this account number and deduct them from your account as one amount? * te: Although Momentum will take great care to always group collections, the grouping can not be guaranteed. The grouping does not include the Momentum Health contribution. 11
Section 6: Details for contribution collection I authorise Momentum to debit the account as supplied on this application form with the amount of the contribution that I have agreed to pay per complementary product. I undertake to inform Momentum of any change in the account details. I authorise Momentum to verify such account details with my financial institution. I accept that Momentum may debit the account on a date other than specified. If a company account is to be debited: I / we warrant that the principal member referred to in this application is an employee of our organisation. Momentum may bill us for the amount due for this member in the same manner as for other members that our organisation employs. Name Position in company Signature of account holder/ Authorised signatory D D _ M M _ 2 0 Y Y Section 7: Terms and conditions For Health Saver 1. I, the undersigned (the Investor ), agree to be bound by the rules and conditions applicable to the Health Saver and the terms and conditions of the Loan Agreement as set out in the Rules and Conditions. 2. I hereby appoint Momentum as my agent for the purpose of collecting and depositing all contributions in respect of the Health Saver with FNB Corporate, and I: Confirm that, in doing so, Momentum acts as my agent; Assume, except insofar as there may be a right of recovery against Momentum, all risks connected with the administration of the entrusted funds by Momentum, as well as the responsibility to ensure that Momentum executes the instruction as recorded herein; Agree that I shall direct all enquiries and instructions in respect of the Health Saver to Momentum. Credit granting for applications 1. I confirm that the above information is true and complete. 2. I understand that the information provided under the Credit Assessment Inventory will yield a Net income figure and that this will determine whether credit will be granted. 3. I understand that the maximum credit I can qualify for is R18 000. 4. I agree that ad-hoc contributions and rebates will not affect the credit advanced to me. 5. I agree that my application is subject to verification, processing and screening and that Momentum may decline an application based on these checks. In addition I give consent that upon acceptance my application will still be subject to continuous screening which may lead to the termination of my application when necessary. 6. I understand that credit granted will be subject to a variable interest rate. For Multiply 1. I, the principal member, hereby apply for my dependants (where applicable) and me to become members of Multiply, which is administered by Momentum Interactive (Pty) Ltd. If Momentum Interactive (Pty) Ltd accepts this application then this application will serve as evidence that I agree to be bound by the rules of Multiply and undertake to adhere to such rules at all times. I may obtain a copy of the rules from the Momentum website (www.momentum.co.za) or the Multiply client contact centre at 0861 88 66 00. 2. I consent to paying the monthly contributions in return for the benefits supplied by Multiply to my dependants (where applicable) and myself. I understand that it is my sole responsibility to ensure that my monthly contributions are received by Momentum Interactive (Pty) Ltd. 3. I acknowledge that Momentum Interactive (Pty) Ltd reserves and shall have the right to cancel the membership applied for herein if I or any of my dependants (that are members of the programme by virtue of this application) breach any of the terms and conditions of this agreement inclusive of rules and regulations pertaining to the Multiply programme in force from time to time. 4. Momentum Interactive (Pty) Ltd reserves the right to amend the rules referred to in 1 above and the Multiply benefits unilaterally from time to time, but shall inform members of any such amendments. I understand that I may cancel my participation on Multiply at any time, including when I do not accept the amended rules and benefits. For Advice Fee 1. I acknowledge that my financial adviser has agreed to render certain services to me arising from my membership of Momentum Health Medical Scheme (Momentum Health), for a monthly fee per principal member as provided for in regulation 28(6)(b) of the Medical Schemes Act. These amounts include VAT, if applicable. 2. The services that my financial adviser has agreed to render to me include, but are not limited to: handling enquiries in relation to my membership of Momentum Health keeping Momentum Health informed of changes in my membership details informing me of changes in my contributions to Momentum Health, and advising me of changes to the product and benefits that Momentum Health offers. 3. This fee may be reviewed annually when my contributions to Momentum Health are reviewed and increased by a rate based on the average contribution increase to Momentum Health. I will receive reasonable written notice of any such intended change. 4. The agreement will start when I become a member of Momentum Health, unless stated otherwise, and will end when my financial adviser is not entitled to receive compensation for my membership of Momentum Health for any reason whatsoever. 12
Section 7: Terms and conditions (continued) For Advice Fee 5. I acknowledge that this fee will not form part of my contribution to Momentum Health and will therefore be a separate charge. 6. I instruct Momentum Group Ltd to collect the above fee, on the due date, in terms of the payment details given in this application and pay my financial adviser on my behalf. For Health Waiver I accept and understand that I am limiting my right to privacy. However, to enable the assessment of the risks and the calculation of the premium and to assist in considering any claim for benefits under this or any other application for insurance that I have made or that was made for me as the insured life, I authorise the Momentum Group Limited, a registered long-term insurer, including the current and future subsidiaries and/or representatives (Momentum): to obtain from any person, including Momentum Health and their administrators, any information that Momentum needs in connection with this application or the policy. I also authorise and instruct such person to give the said information to Momentum, and to share with other insurers that information and any information in this application or in any related policy or other document, either directly or through a database operated by or for insurers as a group, at any time (even after my death) and in such detailed, abbreviated or coded form as Momentum or the operators of such database may decide from time to time, and to disclose my medical information to any parties that Momentum uses in providing services in connection with the policy. I acknowledge that I cannot cancel this authorisation and that it will endure after my death. I declare and confirm the following: 1. This document and any documents that were submitted in connection with it form the basis of the contract I intend entering into, and all information that I have supplied is correct and complete. 2. I undertake to let Momentum know in writing if a change takes place in the health of the insured life/lives between the date of this application and the starting date of the policy or the acceptance date, whichever occurs last. 3. Only the conditions in the contract will bind Momentum and not the representations or undertakings that any person makes or gives. 4. I consent that Momentum may inform anyone who later owns this policy if Momentum adjusts the benefits or the premium under this policy for any reason. 5. I understand that Momentum will cancel the insurance contract that it has issued under this application if the insured life/lives has/have withheld any material information on this application form, or answered any question/s incorrectly, and that the policyholder will forfeit all premiums that he/she paid. 6. I understand that I may cancel this contract within 30 days of the date of the letter of acceptance. I also understand that if I use this right, Momentum will pay back all premiums that I have paid, after Momentum has deducted the cost of any benefits I have enjoyed, the cost of any investment and/or currency risk exposure, and certain expenses. 7. I acknowledge that I have read the valid and official quotation that Momentum has issued that sets out the policy benefits for which I have applied in the properly completed policy application. I confirm that my authorised financial adviser has explained the contents of the quotation to me and I agree that the details set out in it will bind me. 8. I acknowledge and understand that the Momentum Group Limited and/or any of its subsidiaries, agents and/or authorised representatives will not be responsible for any damage or loss that I sustain if I sign this application before completing it in full. I acknowledge and understand that it is an offence to sign a blank or incomplete application form, as stated in the Policyholder Protection Rules that have been published under the Longterm Insurance Act of 1998. 9. I am aware that any information provided for the purpose of this application is subject to the stipulations of the Financial Intelligence Centre Act 38 of 2001 and that it will be dealt with in accordance with requirements that the Act contains. 10. I acknowledge that I have read the declaration above, that I fully understand the nature and effect of it and that it will bind me. 11. I accept all legal risks associated with communicating with Momentum via the electronic medium that I chose in this communication, and I indemnify and hold Momentum harmless against any consequent loss that I or any third party may suffer as a result of the misuse, misapplication, or misinterpretation of this communication. In the event of a conflict between the contents of this communication and any subsequent written instruction of the policyholder, this communication will take precedence, and will be binding on the policyholder, provided that this communication has been properly completed and is regular on the face of the document. Signed at Signature of principal member Date D D _ M M _ 2 0 Y Y 13
Request to appoint a financial adviser Important notes Complete this form to change your financial adviser. Requests must be received before the 15th of every month for the change to be effective on the first of the following month and cannot be backdated. If an employer is appointing a new financial adviser, section 5 may only be signed by authorised person. Return this form to your Momentum Marketing Adviser or fax it to 031/580-0437. Section 1: Member Details Member number Surname Initials Section 2: Employer Details Employer name Group number Section 3: New financial adviser s details Surname Initials Broker house Personal code Telephone House code Cell phone E-mail adress Signature of financial adviser Date D D _ M M _ 2 0 Y Y Section 4: Marketing adviser s details Surname Initials Personal code Telephone MDS branch E-mail address Section 5: Authorisation by member or employer Surname Initials First name Designation Signature of authorised signatory Date D D _ M M _ 2 0 Y Y HEALTH054 0110E 1