The name of the Scheme is the DE BEERS BENEFIT SOCIETY, hereinafter referred to as the "SOCIETY".
The SOCIETY, in its own name, is a body corporate, capable of suing and of being sued and of doing or causing to be done all such things as may be necessary for or incidental to the exercise of its powers or the performance of its functions in terms of the Medical Schemes ACT and regulations and these rules.
The registered office of the SOCIETY is situated at 84 Dutoitspan Road, Kimberley, but the BOARD may transfer such office to any other location in the Republic of South Africa, should circumstances so dictate.
In these rules, a word or expression defined in the Medical Schemes Act (Act 131 of 1998) bears the meaning thus assigned to it and, unless inconsistent with the context:
4.1 "Act",
the Medical Schemes Act (Act No 131 of 1998), and the regulations framed thereunder.
4.2 "Approval",
prior written approval.
4.3 "Area of Operation",
benefits are granted within the Republic of South Africa, Botswana, Namibia, Zambia and Zimbabwe. The area may be extended at the discretion of the BOARD to include Lesotho and Swaziland.
4.4 "Auditor",
an AUDITOR registered in terms of the Public Accountants' and Auditors' Act, 1991, (Act No. 80 of 1991).
4.5 "Beneficiary",
a MEMBER or a person admitted as a DEPENDANT of a MEMBER.
4.6 "Board",
the BOARD of Trustees constituted to manage the SOCIETY in terms of the ACT and these rules.
4.7 "Child",
a MEMBER’s natural child, or a stepchild or legally adopted child or a child who has been placed by a competent authority in the custody of the MEMBER or his SPOUSE or PARTNER or the child born by a MEMBER's natural child, or a stepchild or legally adopted child and who is registered as a DEPENDANT at the time of the birth of such child.
4.8 "Child Dependant",
means a DEPENDANT CHILD, who is under the age of 26.
4.9 "Condition specific waiting period",
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-month period ending on the date on which an application for membership was made.
4.10 "Continuation Member",
a MEMBER who retains his MEMBERSHIP of the SOCIETY in terms of rule 6.2, rule 6.4 or a DEPENDANT who becomes a MEMBER of the SOCIETY in terms of rule 6.3.
4.11 "Contracted fee",
the fee determined in terms of an agreement between the scheme and a service provider or group of providers in respect of the payment of the relevant health service.
4.12 "Contribution",
in relation to a MEMBER, the amount, exclusive of interest, paid by or in respect of the MEMBER and his registered DEPENDANTs if any, as MEMBERSHIP fees.
4.13 "Council",
the Council for Medical Schemes as contemplated in the ACT.
4.14 "Cost",
in relation to a benefit, the net amount payable in respect of a Relevant Health Service.
4.15 "Creditable coverage",
any period which a LATE JOINER was -
4.15.1 a MEMBER or a DEPENDANT of a medical scheme;
4.15.2 a MEMBER or a DEPENDANT of an entity doing the business of a medical scheme which, at the time of his membership of such entity, was exempt from the provisions of the ACT;
4.15.3 a uniformed employee of the South African National Defence Force, or a DEPENDANT of such employee, who received medical benefits from the South African National Defence Force; or
4.15.4 a member or dependant of the Permanent Force Continuation Fund, but excluding any period of coverage as a dependant under the age of 21 years.
4.16 "Dependant",
4.16.1 a MEMBER’s SPOUSE or PARTNER who is not a MEMBER or a registered dependant of a MEMBER of a medical scheme;
4.16.2 a MEMBER’s CHILD who is dependent on the member and is not a member or a registered dependant of a member of a medical scheme;
4.16.3 a member of the Member’s immediate family for whom the member is liable for family care and support;
4.16.4 the ex-spouse of a Member who became a Member of the Society as a result of the transfer of De Beers employees from the Anglo American Corporation Medical Scheme (AACMED) to the Society in 2002 and who was registered as a dependant of such Member in terms of the Rules of AACMED.
4.17 "Dependant Child",
4.17.1 a child under the age of 21; or
4.17.2 a child over the age of 21 but under the age of 26 who is not in receipt of a regular income of more than R2 500,00 per month; or
4.17.3 a child over the age of 21 who, due to a mental or physical disability, is dependent upon the Member.
4.18 "Employee",
a person in the employment of an Employer or Associated Employers.
4.19 "Designated service provider",
a healthcare provider or group of providers selected by the scheme as preferred provider/s to provide to the members, diagnosis, treatment and care in respect of one or more prescribed minimum benefit conditions.
4.20 "Domicillium citandi et executandi",
the MEMBER’S chosen physical address at which notices in terms of rules 11 and 13 as well as legal process, or any action arising therefrom, may be validly delivered and served.
4.21 "Emergency medical condition",
the sudden and, at the time, unexpected onset of a health condition that required immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy.
4.22 "Employer",
De Beers Group Services (Proprietary) Limited.
4.23 "Associated Employers ",
De Beers Consolidated Mines Ltd., DTC South Africa, DTC Valuations Namibia (Pty.) Ltd., De Beers Benefit Society, De Beers Namibia (PTY.) Ltd., De Beers Marine (Pty.) Ltd., De Beers Marine Namibia (Pty.) Ltd., De Beers Pension Fund, Debswana Diamond Company (Pty.) Ltd., Namdeb Diamond Corporation (Pty.) Ltd., Petra Diamonds Ltd. and any other company, organisation of affiliate that has a specific association or relationship with the “EMPLOYER or ASSOCIATED EMPLOYERS”, approved as such by the “EMPLOYER or ASSOCIATED EMPLOYERS”, with or without any restriction on MEMBERSHIP as the “EMPLOYER or ASSOCIATED EMPLOYERS” may impose.
4.24 "General waiting period",
a period in which a BENEFICIARY is not entitled to claim any benefits.
4.25 "Immediate Family"
a Member’s parent (including an adoptive parent), brother and sister.
4.26 "Income",
for the purposes of calculating CONTRIBUTIONs in respect of —
4.26.1 a MEMBER who is an EMPLOYEE - gross monthly basic salary or the benefit value of the Member’s total remuneration package as determined by that Member’s employer and incorporated into such Member’s conditions of employment;
4.26.2 a MEMBER who registers a SPOUSE or PARTNER, who is also an employee of the employer, as a DEPENDANT — the higher of the MEMBER’s or SPOUSE’s or PARTNER’s basic salary or the benefit value of the MEMBER’s or SPOUSE’s or PARTNER’s total remuneration package as determined by that MEMBER’s or SPOUSE’s or PARTNER’s employer and incorporated into such MEMBER’s or SPOUSE’s or PARTNER’s conditions of employment;
4.26.3 a CONTINUATION MEMBER -
4.26.3.1 who retired on or before 31 December 1996, gross monthly earnings;
4.26.3.2 who retired on or after 1 January 1997 but before 1 January 2000, the MEMBER’s last gross monthly basic salary received from the EMPLOYER or ASSOCIATED EMPLOYERS immediately prior to becoming eligible for CONTINUATION MEMBERSHIP;
4.26.3.3 who retired or was retrenched after 31 December 1999, the category of INCOME on Annexure “A” in which the MEMBER was categorised immediately prior to becoming eligible for CONTINUATION MEMBERSHIP.
4.27 "Late Joiner",
an applicant or the adult dependant of an applicant who, at the date of application for membership or admission as a DEPENDANT, as the case may be, is 35 years of age or older but excludes any BENEFICIARY who enjoyed coverage with one or more medical schemes as from a date preceding 1 April 2001, without a break in coverage exceeding 3 consecutive months since 1 April 2001.
4.28 "Member",
any person who is admitted as a MEMBER of the SOCIETY in terms of these rules, membership shall have a corresponding meaning;
4.29 "Member family",
the MEMBER and all the registered DEPENDANTs;
4.30 "Mining areas",
Alexander Bay; Cullinan and the adjacent area of Zonderwater, Rayton and Refilwe; Danielskuil; Jwaneng; Kimberley; Koffiefontein; Kleinzee and areas controlled by Namaqualand Mines; Lime Acres; Messina; Oranjemund and areas controlled by Namdeb Diamond Corporation (Pty) Ltd.; Orapa and Letlhakane.
4.31 "National Health Reference Price List (NHRPL)",
the reference price list for health services published by the COUNCIL for Medical Schemes.
4.32 "Partner",
a person with whom the MEMBER has a committed and serious relationship akin to a marriage based on objective criteria of mutual dependency and a shared and common household, irrespective of the gender of either party.
4.33 "Pre-existing sickness condition",
means a sickness condition for which medical advice, diagnosis, care or treatment was recommended or received within the twelve-month period ending on the date on which an application for MEMBERSHIP was made;
4.34 "Prescribed minimum benefits",
the benefits contemplated in section 29(1) (o) of the ACT and consistent with the provision of the diagnosis, treatment and care costs of –
(a) the Diagnosis and Treatment Pairs listed in Annexure A of the Regulations, subject to any limitations specified therein; and
(b) any EMERGENCY MEDICAL CONDITION.
4.35 "Prescribed minimum benefit condition",
a condition contemplated in the Diagnosis and Treatment Pairs listed in Annexure A of the Regulations or any EMERGENCY MEDICAL CONDITION.
4.36 "Registrar",
the REGISTRAR or Deputy REGISTRAR/s of Medical Schemes appointed in terms of Section 18 of the ACT.
4.37 "Scheme rate",
the reimbursement rate negotiated with service providers. Where no such rate exists, the National Health Reference Price List will apply.
4.38 "Social pension",
the appropriate maximum basic SOCIAL PENSION prescribed by regulations promulgated in terms of the Social Assistance Act, 1992 (Act No. 59 of 1992).
4.39 "Spouse",
the person to whom the MEMBER is married in terms of any law or custom.
