Exclusions and Limitations

Exclusions

Except for certain relevant health services covered by the Prescribed Minimum Benefits delivered to beneficiaries in accordance with protocols and formularies used by the Society or its contracted managed care providers, and unless otherwise provided for in the Rules, expenses incurred in connection with any of the following will not be paid by the Society:

Expenses incurred by a beneficiary because of wilful self-inflicted injury, attempted suicide or the excessive use of an intoxicating substance or drug.
Expenses arising from injuries sustained as a result of participation in professional sport.
Expenses arising from injuries or illness when breaching the law.
Expenses arising from examinations, treatment and/or operations for cosmetic purposes, infertility, artificial insemination, impotency and erectile dysfunction or treatment of an experimental nature or not published in international evidence based treatment or management guidelines, and any complication that may arise from such examinations or treatment.
Expenses (including expenses relating to any Prescribed Minimum Benefit) incurred outside the RSA, unless the expense are incurred by members resident in Botswana or Namibia under the conditions described in the benefit document.
Expenses incurred by a beneficiary during any waiting period imposed by the Society in terms of its Rules.
Expenses in respect of the treatment of any learning, marital, social or family problems.
Expenses relating to the purchase of:
- any drug or medicine not registered by the Medicines Control Council or similar authority; or
- medicines not registered for treatment of the condition for which such medicines are obtained and any patent and household remedies.
Expenses relating to any contraceptive preparations and devices, except for the Mirena device where prior authorisation has been obtained from the Society.
Expenses relating to services that do not relate to any sickness condition, including but not limited to examinations for insurance, employment, visas, pilot and driving licenses and school readiness tests.
Expenses relating to any reduction mammaplasty.
Expenses relating to any recuperative or convalescent holidays.
Expenses relating to any diagnostic preparations and instruments, soaps, shampoos and other topical applications (of a cosmetic nature), medicated or otherwise but excluding those intended for treatment of lice, scabies and other parasitic or fungal infections.
Expenses relating to any anti-addiction and anti-habit agents.
Expenses relating to any cosmetic items inclusive of hair-restorers.
Expenses relating to any sun screening and sun-tanning agents except those intended for the treatment of skin disorders.
Expenses relating to any homeopathic and herbal medicines and remedies not prescribed by a registered homeopath.
Expenses relating to any food supplements including all patent and baby foods and special milk preparations.
Expenses relating to any household bandages, dressings and diapers.
Expenses relating to any syringes and needles except those required for use in the treatment of diabetes.
Expenses relating to any vitamins, mineral supplements, growth hormones and tonics including but not limited to Efamol G and similar products, stimulants e.g. Reactivan, except vitamins e.g. Vitamin B and probiotics needed in conjunction with antibiotics. However, benefits will be granted for the following:
- Pre-natal vitamins; and
- Calcium supplements when prescribed and approved for the treatment of osteoporosis.
Expenses relating to any contact lens preparations.
Expenses relating to any demand prescriptions.
Expenses relating to any telephone prescriptions, other than for repeat prescriptions.
Expenses relating to any telephonic consultations.
Expenses relating to accommodation and nursing services rendered in convalescent or old age homes or similar institutions catering for the aged or chronically ill other than specifically provided for in the Rules.
Expenses relating to all non-prescription sunglasses.
Expenses relating to appointments not kept by a beneficiary.
Expenses relating to sleep therapy.
Expenses relating to an illness of a protracted nature, if the Beneficiary, at the request of the Society, fails to consult a specialist nominated by the Society in consultation with the attending practitioner or fails to act upon the treatment proposed by such specialist.
Expenses incurred without a pre-authorisation being issued by the Society as required by the Rules.
Expenses relating to services which are regarded as not being medically necessary, provided that a treatment, procedure, supply, medicine, hospital or specialised centre stay (or part of a hospital or specialised centre stay) shall be regarded as medically necessary if:
- The treatment is required to restore the normal function of an affected limb, organ or system;
- The treatment is generally accepted as optimal and necessary for the specific condition and is supplied at an appropriate level to render safe and adequate care;
- The treatment is not rendered for the convenience of the relevant beneficiary or service provider;
- Outcome studies are available and acceptable to the Society; and
- No alternative exists that has a better outcome, is more cost effective and has a lower risk.
In this regard, the presence or absence of a medical necessity shall be determined by the Society taking into account the above requirements. The fact that a provider has prescribed, recommended, approved or provided a treatment, service, supply or confinement shall not in itself be regarded as proof that such service was medically necessary. The Society may refer cases to a medical specialist for an opinion. The decision of the Society on the issue of medical necessity following the advice of such specialist shall be final.
Expenses for which a third party is liable including expenses associated with occupational injuries and diseases, motor vehicle accidents and medical services covered by other forms of insurance, provided that the Society may provide benefits until the third party’s liability has been established at which stage the expenditure shall be recouped from the third party or the beneficiary as the case may be.

LIMITATIONS

The maximum benefits to which a member and his Dependants are entitled during any financial year of the Society are limited to the extent set out in Annexure B of the Rules.
Beneficiaries admitted during the course of a financial year are entitled to the benefits set out in Annexure B of the Rules, but subject to reduced maximum benefits calculated in the same proportion as the period of Membership and/or registration as a Dependant measured from the date of admission to the end of the relevant financial year shall bear to the duration of the full financial year.
Any benefits obtained by a Beneficiary under the Prescribed Minimum Benefits shall be off-set against any other applicable benefit limit available in terms of these Rules, at a facility the Society deems appropriate.