In-hospital Treatment

Overall Annual Limit (OAL): R400 000 Per Beneficiary
  • Overall annual limit (OAL): R400 000 per beneficiary

  • Hospitalisation
    Including ward and theatre fees, ICU and high care wards, medication, material, equipment, blood transfusions and transfer of blood.

    Subject to pre-authorisation

    Excluding: Cost of dental implants, accommodation in a private ward, refractive surgery, organ transplants (see organ transplant benefit) and to-take-out (TTO) medication (see acute medication benefit).

    Common benefits subject to OAL

    100%

    of Scheme rate

  • Accidents and injuries
    Including motor vehicle accidents (MVAs)

    Subject to pre-authorisation
    Including injuries relating to third-party cases.

    Common benefits subject to OAL

    100%

    of Scheme rate

  • Maternity benefits
    Confinements in hospital

    Subject to pre-authorisation

    Vaginal and caesarean deliveries in private and State hospitals (includes complications for mother and child).

    Common benefits subject to OAL

    100%

    of Scheme rate

    Home deliveries by a registered nurse/midwife and antenatal visits

    Subject to pre-authorisation

    Benefit includes all costs relating to hospitalisation.

    Common benefits subject to OAL

    100%

    of cost

  • Medical practitioners
    In-hospital treatment (consultations and services in hospital)

    Subject to pre-authorisation

    Treatment and consultations in hospital by specialist and general practitioners (GPs), technicians and physiotherapy.
    Excluding costs for maxillofacial and oral surgery, except for oncology cases.

    Common benefits subject to OAL

    100%

    of Scheme rate

  • Ambulance services (emergency services)
    Road ambulances, emergency services, general advice line, air evacuation and transportation.

    Pre-authorisation required - contact Netcare 911 on 082 911.

    R3 200 per family if Netcare 911 is not used

    100%

    of Scheme rate

  • Internal prostheses and appliances
    Including pacemakers, electronic devices, coronary stents and joint replacements.

    Subject to pre-authorisation

    R51 730 per family per annum subject to OAL

    100%

    of agreed cost

  • Renal disorders (kidney and home dialysis)
    Including related medication therapy (through approved healthcare providers only).

    All cases subject to full investigation, registration on the Renal Management Programme and pre-authorisation

    R228 100 per family subject to OAL

    100%

    of cost

  • Organ transplants
    Subject to prescribed minimum benefits [PMBs]

    Subject to transplant motivation, PMBs and pre-authorisation.

    Including organ harvesting and immunosuppressive medication therapy.

    100%

    of cost

  • Mental Health
    In and out of hospital including psychological conditions

    Subject to pre-authorisation of all related services at approved facilities

    Hospital admissions for mental health conditions include anorexia nervosa, bulimia nervosa, treatment for alcohol and chemical substance abuse and other mental health conditions.

    R48 200 per family per annum - 21 days per beneficiary

    100%

    of cost