1. Events you want to claim for, but you are not an insured person at the time of the event.
2. Events that occur outside of your policy waiting period(s), unless you are claiming for an accidental event or a medical emergency where applicable.
3. Events where a benefit or overall policy limit has been reached.
4. Events where your policy does not provide the appropriate benefit for you to claim from.
5. Events where pre-authorisation was not requested or granted, or where an appropriate healthcare provider referral was not obtained.
6. Events where the healthcare providers utilised do not form part of the provider network, unless a benefit specifically makes provision for cover.
7. Healthcare services that do not form part of our list of approved tarrif codes or formularies, where applicable.
8. In-patient or out-patient hospital or casualty admissions where the medical event was not due to an accidental event or emergency, where applicable.
9. Medical procedures performed as part of in-patient stabilisation except for the cost of stabilisation required in the event of an emergency, where the medical event is the result of a sudden, and at the time unexpected onset of a medical condition that requires immediate medical treatment.
10. Physiotherapy or occupational therapy for physical rehabilitation:
a. not due to an accidental event; or
b. not provided within 3 months after discharge from hospital.
11. MRI or CT scans not required due to an accidental event.
12. Costs incurred for the voluntary stay at a private facility after stabilisation for a medical emergency.
13. Reconstructive cosmetic or maxillo-facial surgery, including related medical conditions and procedures that do not form part of an authorised hospital event due to an accident.
14. Obesity or its sequel, cosmetic surgery or surgery directly or indirectly caused by, related to or in consequence of cosmetic surgery, unless a benefit specifically makes provision for cover.
15. Eye care, other than an eye test, a frame and spectacle lenses covered under our Optometry Benefit.
16. External prosthetic devices or external medical items, such as artificial limbs and wheelchairs.
17. Artificial insemination, infertility treatment and contraceptives.
18. The use of robotic surgery, specialised mechanical or computerised appliances and equipment.
19. Routine physical, diagnostic procedures or examination where there is no objective indication of impairment in your health.
20. Riots, wars, political acts, public disorder, terrorism, civil commotions, labour disturbances, strikes, lock-out, or any attempted such acts.
21. A deliberate criminal or fraudulent act, or any illegal activity conducted by you or a member of your household which directly or indirectly results in loss, damage or injury.
22. Attempted suicide, intentional self-injury and deliberate exposure to exceptional danger except when you attempt to save a human life.
23. Events where the use of drugs or alcohol is involved.
24. Participation in:
a. Active military, police or police reservist duty;
b. Aviation, other than a passenger;
c. Hazourdous, competitive or professional sports or activities involving an official or practice, event, race or contest; and
d. Any form of race or speed test, except on foot or involving any non-mechanically propelled vehicle, vessel, craft or aircraft.
25. Nuclear weapons material, ionising radiations or contamination by radioactivity from any nuclear fuel, nuclear waste or from the combustion of nuclear fuel that includes any self-sustaining process of nuclear fission.
26. Events that occur for which the actual damage is provided for by legislation, including contractual liability and consequential loss.
27. Non-disclosure of material information that is likely to affect the assessment or acceptance of risk.
28. Dual insurance where cover is provided by more than one health insurance policy through different insurers, or the same insurer.
29. All costs which are in the opinion of the Underwriting Manager’s clinical review team:
a. not medically necessary or clinically appropriate or do not meet the healthcare needs of the Insured Person;
b. not consistent in type, frequency and duration of treatment.
30. Procedures performed in doctors’ rooms that are not listed in the list of tariff code descriptions.
31. Any medical transportation service for non-emergency purposes.
32. The supply of medication that is not listed on the Underwriting Manager’s (Mediscor) formulary list (Formulary List to be defined).
GAP COVER CORE BENEFITS
IN-HOSPITAL BENEFITS
This benefit provides you with cover for the difference in the amount charged by a Registered Medical Professional and the Medical Scheme Rate for services rendered while admitted in hospital.
This benefit provides you with cover for shortfalls on all dental procedures paid from risk limited to R5 500 per policy, per annum.
OUT-OF-HOSPITAL BENEFITS
This benefit provides you with cover for shortfalls on Gastroscopies and Colonoscopies performed in the GP or Specialist’s rooms, limited to 2 scopes per beneficiary, per annum.
This benefit provides you with cover for the shortfalls on cost incurred for the treatment of an injury caused by an external force at an emergency ward limited to 2 events to a maximum benefit of R4 000 per policy, per annum provided that payment was made by the Medical Scheme.
This benefit provides you with cover for out of hospital physiotherapy limited to R1 000 per policy, per annum for postoperative joint replacement/back surgery rehabilitation provided that payment was made by the Medical Scheme for services rendered within 30 days after discharge.
Unity Health is a division of Ambledown Financial Services (PTY) Ltd, an authorised FSP 10287. In partnership with Optivest Health Services, an authorised FSP 13475. Unity Health Insurance is not a medical aid scheme but a short-term insurance product underwritten by Bryte Insurance Company Limited, a licensed insurer and an authorised FSP 17703.
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