The Comprehensive Plans offer you extensive cover in hospital and comprehensive day-to-day benefits

Extensive in-hospital and out-of-hospital cover

• Unlimited hospital cover in any private hospital or our network of hospitals on the Delta network options
• Comprehensive cover for chronic medicine
• Cover for innovative medical technologies and expensive medicines, including cover for evidence-based treatment not available in South Africa
• A high Medical Savings Account to cover your day-to-day healthcare needs
• High day-to-day limits and an Above Threshold Benefit to extend your cover
• Cover for up to 90 days up to R5 million for each person for medical emergencies when travelling outside South Africa

Make the Full Cover Choice 
We offer you the choice to be covered in full for hospitalisation, specialists in hospital, chronic medicine and GP consultations. Look out for the Full Cover Choice stamp in this brochure. It shows you when to use our range of online tools that help guide you to full cover.

Your cover in hospital
Comprehensive hospital cover

We cover you in any private hospital for emergencies and for planned hospital admissions that you have authorised with us. There is no overall limit.

Emergency cover when you need it most

In an emergency, go straight to hospital. If you need medically equipped transport, call 0860 999 911. This line is managed by highly qualified emergency personnel who will send the most appropriate air or road emergency evacuation transport to you. It is important that you, a loved one or the hospital let us know about your admission as soon as possible.

Cover for planned hospital admissions

Please call us 48 hours before you go to hospital to confirm your admission.

Limits, clinical guidelines and policies apply to some healthcare services and procedures in hospital.

Going to hospital can be a stressful experience. Discovery’s HospitalXpress makes your admission to hospital convenient and seamless. This service offers you express pre-admissions and online tools to authorise your admission and confirm your cover. HospitalXpress also connects you to select partners, bringing you a range of value-added services at the reduced prices you’re accustomed to as a Discovery member.

Use a network hospital on the Delta network options

On the Classic and Essential Delta Comprehensive network options, you are covered in full at hospitals in he Delta Hospital Network. For planned admissions at any other private hospital, you must pay an amount of 4 550 upfront to the hospital.

Your cover for healthcare professionals 
Full cover for specialists who we have an agreement with You can benefit by using healthcare professionals who we have an agreement with because we will cover their approved procedures in full.

If you are a Classic member, you benefit from access to the broadest range of specialists who we pay in full, which represents over 88% of our members’ specialist interactions. These healthcare professionals, appropriate to your plan, are also the designated providers for Prescribed Minimum Benefits.

You may have a co-payment if you use other specialists

If you are treated by a specialist who we do not have an agreement with, we cover you up to 200% of the Discovery Health Rate on the Classic Plans and up to 100% of the Discovery Health Rate on the Essential Plans. You may have a co-payment if your specialist charges above these rates.

Other healthcare professionals

We cover GPs and other healthcare services up to 200% of the Discovery Health Rate on the Classic Plans and up to 100% of the Discovery Health Rate on the Essential Plans.

We cover radiology and pathology up to 100% of the Discovery Health Rate on all plans.

Your cover for investigations
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy)

We pay the first R2 100 of your hospital account from your day-to-day benefits. We pay the balance of the hospital account and your related accounts from your Hospital Benefit. A related account is the account from your admitting doctor, anaesthetist or any approved expense you incur during your hospital admission, other than the hospital account.

MRI and CT scans

If your MRI or CT scan is done as part of an approved admission, we pay it from your Hospital Benefit at 100% of the Discovery Health Rate.

If you are admitted for conservative back or neck treatment, or if the scan is not related to your admission, we pay the first R2 300 of the scan code from your day-to-day benefits. We pay the balance of the scan code from your Hospital Benefit, up to 100% of the Discovery Health Rate. Specific rules and limits apply to conservative back and neck scans.  

Your cover for dental treatment

You need to pay a portion of your hospital or day-clinic account upfront for dental admissions.

This amount varies, depending on your age and the place of treatment.

We pay the balance of the hospital account from your Hospital Benefit, up to 100% of the Discovery Health Rate. We pay the related accounts, which include the dental surgeon’s account, from your Hospital Benefit, up to 100% of the Discovery Health Rate.

No overall dental limit

There is no overall limit for dental treatment. However, all dental appliances, their placement, and orthodontic treatment (including related accounts for orthognathic surgery) are paid at 100% of the Discovery Health Rate from your day-to-day benefits, up to an annual limit of R17 400 a person. If you join the medical scheme after January, you won’t get the full limit because it is calculated by counting the remaining months in the year.

Severe dental and oral surgery

The Severe Dental and Oral Surgery Benefit covers a defined list of procedures, with no upfront payment and no overall limit. This benefit is subject to authorisation and the Scheme’s clinical rules.

Unlimited healthcare services

Most of your in-hospital healthcare services have no overall limit. These are:

• GPs                                                                                                               
• Specialists
• Pathology                                                                                                 
• Radiology
• Allied healthcare professionals, like physiotherapists        
• HIV cover

Limited healthcare services

Only the following healthcare services have an annual limit:

* If you join the medical scheme after January, you won’t get the full limit because it is calculated by counting the remaining months in the year.

Delta Hospital Network for 2012

You are covered in full at the hospitals in the Delta Hospital Network, which means you do not have to pay an amount before you are admitted. For planned admissions to any other private hospital, you must pay an amount of R4 550 upfront to the hospital. This does not apply in emergencies.

Delta Hospital Network

MaPS Advisor is our medical provider and hospital ssearch tool. It will help you find a healthcare professional or provider with whom we have an agreement, which means they charge the Discovery Health Rate and we pay them in full.

DiscoveryCare looks after you in times of need

Your cover for chronic conditions

You have extensive cover for a comprehensive list of chronic conditions. You have full cover for approved medicine on Discovery Health’s medicine list, which is our most extensive. If you choose to use medicine that is not on the medicine list, you have a set monthly amount available that is higher than that of our other plans.

We pay medicine up to the Discovery Health Medicine Rate. We need to approve your chronic condition before it is covered from the Chronic Illness Benefit.

When you use MedXpress, Discovery’s convenient medicine delivery service, you pay no delivery or administration fees. Discovery’s qualified service agents can also advise you on the most cost-effective alternatives and you will always be charged at the Discovery Health Medicine Rate or less – minimising co-payments. Call us on 0860 99 88 77 to make use of this free service.

Your cover for medical technology and expensive medicine

You have cover for a defined list of the latest treatments through the Specialised Medicine and Technology Benefit, up to R200 000 for each person each year. Please call us to see whether your treatment qualifies.

You also have access to the Overseas Treatment Benefit, which covers you when you travel to seek evidence-based healthcare treatment not available in South Africa. The treatment must be at a registered healthcare professional and is paid up to a limit of R500 000 for each person each year. You will need to pay and claim back from us when you return to South Africa.

Specific rules and a co-payment of up to 20% applies to both benefits.

Your cover for cancer treatment

Our Oncology Programme covers the first R400 000 of approved cancer treatment over a 12-month cycle. Cover is unlimited once cancer treatment costs go over this amount, but you will need to pay 20% of the cost of all further treatment.

We cover chemotherapy and oncology-related medicine up to the Discovery Health Medicine Rate.

We pay consultations, radiotherapy, radiology, pathology, scopes and scans up to 100% of the Discovery Health Rate.

You might have to make a co-payment if your healthcare professional charges more than the Discovery Health Rate.

Cancer treatment that is a Prescribed Minimum Benefit is always covered in full. Please call us to register on the Oncology Programme.

Your cover for day-to-day medical expenses

We pay for day-to-day medical expenses like GP visits, radiology and pathology from your Medical Savings Account, as long as you have money available. If you run out of money in your Medical Savings Account before your claims add up to the Annual Threshold, you will have to pay for your day-to-day medical expenses yourself.

 Annual Medical Savings Account amounts

* We count a maximum of three children when we work out the monthly contributions.

 If you join the medical scheme after January, your Medical Savings Account will be calculated by counting the remaining months in the year.

Once your claims add up to the Annual Threshold, we pay the rest of your claims from the Above Threshold Benefit, at the Discovery Health Rate.

The Insured Network Benefit ensures that you have no gaps in cover for GPs and pathology in our network

We extend your day-to-day cover through the Insured Network Benefit. When you have spent your annual Medical Savings Account deposit, we cover the full cost of your consultation fees if you go to a GP in our network. We also cover pathology at our network providers if your GP or specialist requests the tests by filling in the Discovery Health pathology form (available on our website).

The Above Threshold Benefit offers extra day-to-day cover

The Comprehensive Series has an unlimited Above Threshold Benefit. This gives you extra day-to-day cover after your Medical Savings Account has run out and your day-to-day claims add up to a set amount called the Annual Threshold.

Annual Threshold amounts

The Annual Threshold is calculated by adding:

• R9 300 for the main member
• R9 300 for each adult dependant
• R1 750 for each child (we count a maximum of three children)

If you join the medical scheme after January, your Annual Threshold will be calculated by counting the remaining months in the year.

When you claim, we add up the following amounts to get to the Annual Threshold:

• For Premier Rate specialists, we add up the Premier Rate
• For specialists who we don’t have an agreement with, we add up 100% of the Discovery Health Rate
• For GPs and all other healthcare services, we add up 100% of the Discovery Health Rate
• For generic medicine, we add up 100% of the Discovery Health Medicine Rate
• For non-generic medicine, we add up 75% of the Discovery Health Medicine Rate. We also pay these same amounts from your Above Threshold Benefit.O
• Over-the-counter medicines do not add up to your Annual Threshold or pay from the Above Threshold Benefit.

No annual limit on certain day-to-day healthcare services

We pay these healthcare services from your Medical Savings Account or Above Threshold Benefit, with no annual limit:

• GPs                                         
• Specialists
• Pathology
• MRI and CT scans: we pay the first R2 300 of your MRI or CT scan code from your day-to-day benefits. We cover the balance of the scan code from your Hospital Benefit, up to the Discovery Health Rate (except for conservative back and neck treatment, where specific rules and limits apply).
• Basic dental check-ups
• Radiology

Limits on some day-to-day healthcare services

* If you join the medical scheme after January, you won’t get the full limit because it is calculated by counting the remaining months in the year.

Extending your cover for allied healthcare services

The Allied and Therapeutic Extender Benefit gives you unlimited cover for a list of allied healthcare services, like physiotherapy, if you have reached your Allied and Therapeutic Benefit limit. This unlimited cover is for a defined list of conditions, for example quadriplegia and cerebral palsy. The unlimited cover depends on your condition and the criteria for it.

 How we make your Medical Savings Account last longer

We pay claims for these day-to-day expenses without using your Medical Savings Account:

•   The Screening and Prevention Benefit covers certain tests at a Discovery Wellness Network provider, like blood glucose, blood pressure, cholesterol and body mass index. We also cover a mammogram, Pap smear, PSA (a prostate screening test) and HIV screening tests. Members 65 years or older and members registered for certain chronic conditions are also covered for a seasonal flu vaccine.

•   We will cover out-of-hospital claims for recovery after certain traumatic events from the Trauma Recovery Extender Benefit. The cover applies to the rest of the year in which the trauma took place, and to the year after your trauma.

•   We pay for scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy) from your Hospital Benefit if it’s done in your doctor’s rooms. We pay up to 200% of the Discovery Health Rate if you are on a Classic Plan and up to 100% of the Discovery Health Rate if you are on an Essential Plan. Please call us before you have a scope done in your doctor’s rooms to confirm your benefits.

International Travel Benefit

The International Travel Benefit covers you if you have emergency medical expenses when travelling outside South Africa. The International Travel Benefit provides cover of up to R5 million for a maximum of 90 days from the date of departure from South Africa. You pay the first $150 or €100 of out-of-hospital emergency claims.

The Africa Evacuation Benefit

You have cover for emergency medical evacuations from certain sub-Saharan African countries back to South Africa.

 General exclusions

We do not cover certain healthcare services. Discovery Health will not pay for healthcare services related to or caused by the following, except where specifically listed as part of a defined benefit or where covered by the Prescribed Minimum Benefits:

1.   Cosmetic procedures and treatments

2.   Otoplasty for bat ears, portwine stains and blepharoplasty (eyelid surgery)

3.   Breast reductions or enlargements and gynaecomastia

4.   Obesity

5.   Frail care

6.   Infertility

7.   Wilful, self-inflicted illness or injury

8.   Alcohol, drug or solvent abuse

9.   Wilful and material violation of the law or during a period of imprisonment

10. Wilful participation in war, terrorist activity, riot, civil commotion, rebellion or uprising

11. Injuries sustained or healthcare services arising during travel to or in a country at war

12. Experimental, unproven or unregistered treatments or practices

13. Search and rescue

14. Any costs for which a third party is legally responsible.

We also do not cover the complications or the direct or indirect expenses that arise from any of the exclusions listed above. If we apply a waiting period because you have never belonged to a medical scheme or have had a break in membership of more than 90 days before joining Discovery Health Medical Scheme, you will not have access to the Prescribed Minimum Benefits during your waiting period. This includes cover for emergency admissions.

What you will pay

* We count a maximum of three children when we work out your contribution, Medical Savings Account and Above Threshold Benefit. If an adult dependant does not meet our eligibility criteria we will charge the same contribution as the main member’s contribution.