2015 eng bro final

PRODUCT RANGE2015

The cost of in-hospital medical treatment is on the rise. The shortfall that exists

between what your medical scheme pays and the fee

charged for private healthcare, is growing. For this reason,

Stratum Benefits has designed tailor-made gap

solutions to suit your needs.

BASE 500 PAGE 2

CO-EVOLUTION 500 PAGE 3

COMPREHENSIVE PAGE 4

ELITE PAGE 6

SENIOR 500 PAGE 8

HOSPITAL OPTIMISER PAGE 10

ONCOLOGY PLUS PAGE 11

CORPORATE ELITE PAGE 12

G FORCE PAGE 14

GENERAL EXCLUSIONS PAGE 15

INDEX1

TERMS AND CONDITIONS APPLY | E&OE UNDERWRITTEN BY CONSTANTIA INSURANCE COMPANY

NEW BUSINESS AND POLICY CHANGES

GAUTENG, NORTH WEST AND FREE STATE(t) 086 111 3499 (f) 086 584 4104(e) [email protected]

KWAZULU-NATAL(t) 086 111 3499 (f) 086 267 6318(e) [email protected]

WESTERN, NORTHERN AND EASTERN CAPE(t) 086 111 3499 (f) 086 231 0440(e) [email protected]

CLAIMS

NATIONWIDE(t) 086 111 3499 (f) 086 616 8992(e) [email protected]

CANCELLATIONS

NATIONWIDE(t) 086 111 3499 (f) 086 239 9624(e) [email protected]

DEBIT ORDER QUERIES

GAUTENG, NORTH WEST AND FREE STATE(t) 086 111 3499 (f) 086 231 0437(e) [email protected]

KWAZULU-NATAL(t) 086 111 3499 (f) 086 231 0438(e) [email protected]

WESTERN, NORTHERN AND EASTERN CAPE(t) 086 111 3499 (f) 086 762 8424(e) [email protected]

HEAD OFFICE

STRATUM BENEFITS (PTY) LTD(t) 086 111 3499 (f) 086 633 3761 (e) [email protected] (w) www.stratumbenefits.co.za

Block C, 367 Surrey Avenue, Ferndale, RandburgSuite 386, Private Bag X09, Weltevredenpark, 1715

Reg no: 2003/018155/07

GENERAL CONTACT DETAILS

This option is designed to provide additional cover for tariff shortfalls on doctors and specialists accounts for in-hospital procedures.

GAP BENEFIT

This benefit provides additional cover of 500% above the medical scheme rate.

• Benefit is unlimited

GAP BENEFIT also includes cover for tariff shortfalls for certain in-hospital related accounts:

• Radiology (x-rays) and pathology, limited to R12 000 per insured per annum

• Consumable items, limited to R6 000 per insured per annum• Physiotherapy, limited to R6 000 per insured per annum

CASUALTY BENEFIT

This benefit covers the expenses that may occur at a registered casualty facility for treatment required due to an accident.

Accident: “Bodily injury caused by violent, accidental and external physical means.”

• Benefit is limited to R3 000 per policy per annum

TRAUMA COUNSELLING BENEFIT

This benefit covers counselling sessions with a registered counsellor or clinical psychologist that may be required after a serious or traumatic event due to violence, an accident or on the diagnosis of a dread disease, restricted to the insured lives on the Stratum Benefits policy.

Trauma: “A serious injury or shock to the body due to violence, an accident or on the diagnosis of a dread disease that may cause substantial psychological damage.”


BASE 5002 MONTHLY PREMIUM

INDIVIDUAL / FAMILY

PER ADULT DEPENDANT

R 118

R 60

APPLICABLE FROM INCEPTION OF THE POLICY

• 3 Months general waiting period (no claims can be submitted within the first 3 months of cover unless accidental)

• 6 Months waiting period for tonsillectomy, myringotomy (grommets), adenoidectomy, hysterectomy (except where cancer is diagnosed), joint replacements (unless accidental), hernia repairs (unless an emergency), cataract surgery, endoscopic procedures and related surgery and dental procedures

• 10 Months waiting period for pregnancy and childbirth• 10 Months waiting period for pre-existing medical

conditions and related surgery

GENERAL

• Entry age before 70th birthday• Children will be accepted as child dependants up to and

including the age of 27, provided they are registered dependants on the medical scheme option of either the principal member or the spouse

• From the age of 28, a child dependant will be regarded as an adult and will therefore be charged an adult dependant rate, provided that the dependant is registered on the medical scheme option of either the principal member or the spouse

• Entry age for adult dependants before 70th birthday• The Stratum Benefits policy extends cover to all dependants

as registered on the medical scheme option of either the principal member or the spouse

OVERVIEW UNDERWRITING CRITERIA

UNDERWRITTEN BY CONSTANTIA INSURANCE COMPANY TERMS AND CONDITIONS APPLY | E&OE

This option is designed to provide additional cover for tariff shortfalls on doctors and specialists accounts for in-hospital procedures as well as cover for procedure related co-payments imposed by a medical scheme.

GAP BENEFIT






CO-PAYMENT BENEFIT

This benefit provides cover for co-payments and deductibles imposed by a medical scheme.

Co-payments/Deductibles: “An upfront payment that is required by a medical scheme for the cost of certain procedures.”

• Covers all compulsory co-payments for in-hospital procedures, MRI and CT scans (in- and out of hospital) as well as hospital pre-admission co-payments (no benefit if a non-designated service provider is utilised)


CASUALTY BENEFIT








CO-EVOLUTION 5003 MONTHLY PREMIUM

INDIVIDUAL / FAMILY

PER ADULT DEPENDANT

R 145

R 60






GENERAL






OVERVIEW UNDERWRITING CRITERIA


This option is designed to provide additional cover for tariff shortfalls on doctors and specialists accounts for in-hospital procedures, cover for procedure related and oncology co-payments and where a sub-limit on biological drugs is imposed by a medical scheme.

GAP BENEFIT






CO-PAYMENT BENEFIT





ONCOLOGY BENEFIT

This benefit provides additional cover for oncology related co-payments and where a sub-limit on biological drugs is imposed by a medical scheme.

• Benefit for co-payments and biological drugs (as per the Stratum Benefits formulary) is limited to R350 000 per policy per annum

• A once-off benefit of R5 000 per insured life is payable after policy inception on the first diagnosis of cancer, as per the Stratum Benefits recognised Cancer Categories

COMPREHENSIVE4

OVERVIEW


ADDITIONAL BENEFITS

• GAP POLICY PREMIUM WAIVER BENEFIT covers the monthly premium for a period of 12 months in the event of death, permanent disability or forced retrenchment of the premium payer where the premium payer is a natural person

• MEDICAL SCHEME CONTRIBUTION WAIVER BENEFIT covers the monthly scheme contribution, limited to R4 000 per month per insured family, for a period of 3 months in the event of death or permanent disability of the premium payer where the premium payer is a natural person

• ACCIDENTAL DEATH BENEFIT covers the lives of the principal insured and spouse, limited to R5 000 per life

CASUALTY BENEFIT








5





conditions and related surgery• A total exclusion for any pre-diagnosed cancer is applicable

to the Oncology Benefit

GENERAL






STRATUM BENEFITS FORMULARY LIMITED TO

Herceptin, Mylotarg, Nexavar, Gleevec, Sprycel, Faslodex, Velcade, Tarceva, Alimta, Zevalin, Avastin, Erbitux, Sutent, Fludara, Mabthera with specific oncological condition and/or specific sub-groups of cancers limited to the sub-groups of the following Cancer Categories:

HER 2 + Breast cancer, Acute myeloid leukemia, Advanced hepatocellular carcinoma, Acute lymphoblastic leukemia, Chronic myeloid leukemia, Chronic lymphocytic leukemia, Non-Hodgkins lymphoma, Advanced renal cell carcinoma, Hairy cell leukemia, Myelodysplasia, HER-ve breast cancer, Gastrointestinal stromal tumor, Multiple myeloma, Non-small cell lung cancer, Metastatic colorectal cancer and Head and neck cancer

UNDERWRITING CRITERIA

UNDERWRITTEN BY CONSTANTIA INSURANCE COMPANY

MONTHLY PREMIUMINDIVIDUAL

FAMILY

PER ADULT DEPENDANT

R 167

R 205

R 60

TERMS AND CONDITIONS APPLY | E&OE

This option is designed to provide additional cover for tariff shortfalls on doctors and specialists accounts for in-hospital procedures, cover for procedure related and oncology co-payments and where sub-limits on biological drugs and in-hospital procedures are imposed by a medical scheme.

GAP BENEFIT






CO-PAYMENT BENEFIT





ONCOLOGY BENEFIT




• RECONSTRUCTION BENEFIT, due to a mastectomy, covers the tariff shortfalls up to 300% of the medical scheme rate, provided that cancer is diagnosed after inception of the Stratum Benefits policy

SUB-LIMIT BENEFIT

This benefit provides additional cover when a sub-limit benefit on a medical scheme option has been reached.

Sub-limit: “The limit imposed by a medical scheme for specific in-hospital procedures, but excludes overall annual limits.”

• Benefit is limited to R20 000 per event to a maximum of R60 000 per insured per annum

ADDITIONAL BENEFITS



• ACCIDENTAL DEATH BENEFIT covers the lives of the principal insured and spouse, limited to R5 000 per life and R3 000 per child dependant

CASUALTY BENEFIT








ELITE6

OVERVIEW


7





conditions and related surgery• Pre-diagnosed cancer is covered provided the insured

person is in remission for 5 years either prior to policy inception or during cover on the Stratum Benefits policy, applicable to the Oncology Benefit

GENERAL












FAMILY

PER ADULT DEPENDANT

R 187

R 244

R 60



8This option is designed to provide additional cover for tariff shortfalls on doctors and specialists accounts for in-hospital procedures, cover for procedure related and oncology co-payments and where sub-limits on biological drugs and in-hospital procedures are imposed by a medical scheme.

GAP BENEFIT






CO-PAYMENT BENEFIT





ONCOLOGY BENEFIT



SUB-LIMIT BENEFIT




• Benefit is applicable where a medical scheme sub-limit benefit exceeds R4 000

SENIOR 500

OVERVIEW


9


CASUALTY BENEFIT








UNDERWRITING CRITERIA APPLICABLE FROM INCEPTION OF THE POLICY






GENERAL

• Entry age 70th birthday and older• Children will be accepted as child dependants up to and



• The Stratum Benefits policy extends cover to all dependants as registered on the medical scheme option of either the principal member or the spouse




MONTHLY PREMIUM

INDIVIDUAL / FAMILY

PER ADULT DEPENDANT

R 188

R 60



10This policy is designed as a stand-alone option to provide additional cover in the event that an overall annual hospital limit, imposed by a medical scheme, has been reached and can be taken in conjunction with any gap policy.

• The medical scheme option’s overall annual hospital limit will be increased to R2 000 000 per annum

EXAMPLEMedical Scheme A has an overall annual hospital limit of R300 000. This limit could easily be reached by a prolonged hospital stay. Hospital Optimiser will ensure continuous private medical care by increasing the overall annual limit, thus providing additional cover of R1 700 000. The alternative could result in a forced transfer to a state facility.

HOSPITAL OPTIMISER

MONTHLY PREMIUM

OVERVIEW

APPLICABLE FROM INCEPTION OF THE POLICY• 3 Months general waiting period (no claims can be

submitted within the first 3 months of cover unless accidental)




GENERAL• Entry age before 70th birthday• Children will be accepted as child dependants up to and






Medical Scheme Annual Hospital Limit

Stratum Benefits Cover Premium

R 300 000 R 1 700 000 R 70R 500 000 R 1 500 000 R 60R 800 000 R 1 200 000 R 58R 1 000 000 R 1 000 000 R 56

MONTHLY PREMIUM

SEE TABLE BELOW


This stand-alone policy, which can be taken in conjunction with any gap policy, will provide additional cover for the treatment of cancer, cover for co-payments as well as provide an extended benefit for biological drugs when an overall annual benefit limit, imposed by a medical scheme, has been reached.

This option will provide additional cover for out-patient cancer treatment at a registered oncology facility provided it forms part of the medical scheme’s designated provider network

• Benefit for out-patient cancer treatment is limited to R100 000 per policy per annum

• Benefit for oncology related co-payments and biological drugs (as per the Stratum Benefits formulary), is limited to R100 000 per policy per annum


ONCOLOGY PLUS 11

OVERVIEW



• 3 Months general waiting period (no claims can be submitted within the first 3 months of cover)

• A total exclusion for any pre-diagnosed cancer is applicable

GENERAL










MONTHLY PREMIUM

INDIVIDUAL / FAMILY

PER ADULT DEPENDANT

R 95

R 60

NEW


This option is designed to provide additional cover for tariff shortfalls on doctors and specialists accounts for in-hospital procedures, cover for procedure related and oncology co-payments and where sub-limits on biological drugs and in-hospital procedures are imposed by a medical scheme.

GAP BENEFIT






CO-PAYMENT BENEFIT





ONCOLOGY BENEFIT




• RECONSTRUCTION BENEFIT, due to a mastectomy, covers the tariff shortfalls up to 300% of the medical scheme rate, provided that cancer is diagnosed after inception of the Stratum Benefits policy

SUB-LIMIT BENEFIT




ADDITIONAL BENEFITS



• ACCIDENTAL DEATH BENEFIT covers the lives of the principal insured and spouse, limited to R5 000 per life and R3 000 per child dependant

CASUALTY BENEFIT








EXCLUSIVELY TAILORED FOR CORPORATE EMPLOYER GROUPS ONLY

CORPORATE ELITE 12OVERVIEW


13 MONTHLY PREMIUM

Subject to the demographic profile of the group


• Subject to the demographic profile of the group

GENERAL

• Children will be accepted as child dependants up to and including the age of 27, provided they are registered dependants on the medical scheme option of either the principal member or the spouse










14This option is designed to provide additional cover for tariff shortfalls on doctors and specialists accounts for in-hospital procedures, cover for procedure related and oncology co-payments and where sub-limits on biological drugs and in-hospital procedures are imposed by a medical scheme.

GAP BENEFITThis benefit provides additional cover of 500% above the medical scheme rate.• Benefit is unlimited

GAP BENEFIT also includes cover for tariff shortfalls for certain in-hospital related accounts:• Radiology (x-rays) and pathology, limited to R10 000 per

insured per annum• Consumable items, limited to R5 000 per insured per annum• Physiotherapy, limited to R6 000 per insured per annum

CO-PAYMENT BENEFITThis benefit provides cover for co-payments and deductibles imposed by a medical scheme.Co-payments/Deductibles: “An upfront payment that is required by a medical scheme for the cost of certain procedures.”• Covers all compulsory co-payments for in-hospital

procedures, MRI and CT scans (in- and out of hospital) as well as hospital pre-admission co-payments (no benefit if a non-designated service provider is utilised)


ONCOLOGY BENEFITThis benefit provides additional cover for oncology related co-payments and where a sub-limit on biological drugs is imposed by a medical scheme. • Benefit for co-payments and biological drugs (as per the

Stratum Benefits formulary) is limited to R100 000 per policy per annum


SUB-LIMIT BENEFITThis benefit provides additional cover when a sub-limit benefit on a medical scheme option has been reached.Sub-limit: “The limit imposed by a medical scheme for specific in-hospital procedures, but excludes overall annual limits.”• Benefit is limited to R10 000 per event to a maximum of

R50 000 per insured per annum• Non-PMB procedures in day clinics, limited to R10 000 per

policy per annum

ADDITIONAL BENEFITS• GAP POLICY PREMIUM WAIVER BENEFIT covers the

monthly premium for a period of 6 months in the event of death, permanent disability or forced retrenchment of the premium payer where the premium payer is a natural person

• ACCIDENTAL DEATH BENEFIT covers the lives of the principal insured and spouse, limited to R7 000 per life

CASUALTY BENEFITThis benefit covers the expenses that may occur at a registered casualty facility for treatment required due to an accident.Accident: “Bodily injury caused by violent, accidental and external physical means.”• Benefit is limited to R5 000 per policy per annum

EXCLUSIVELY TAILORED FOR GOVERNMENT EMPLOYEES ONLY

G FORCE

APPLICABLE FROM INCEPTION OF THE POLICY• 6 Months waiting period for tonsillectomy, myringotomy

(grommets), adenoidectomy, hysterectomy (except where cancer is diagnosed), joint replacements (unless accidental), hernia repairs (unless an emergency), cataract surgery, endoscopic procedures and related surgery and dental procedures




GENERAL• Entry age before 70th birthday• Children will be accepted as child dependants up to and





STRATUM BENEFITS FORMULARY LIMITED TO Herceptin, Mylotarg, Nexavar, Gleevec, Sprycel, Faslodex, Velcade, Tarceva, Alimta, Zevalin, Avastin, Erbitux, Sutent, Fludara, Mabthera with specific oncological condition and/or specific sub-groups of cancers limited to the sub-groups of the following Cancer Categories:HER 2 + Breast cancer, Acute myeloid leukemia, Advanced hepatocellular carcinoma, Acute lymphoblastic leukemia, Chronic myeloid leukemia, Chronic lymphocytic leukemia, Non-Hodgkins lymphoma, Advanced renal cell carcinoma, Hairy cell leukemia, Myelodysplasia, HER-ve breast cancer, Gastrointestinal stromal tumor, Multiple myeloma, Non-small cell lung cancer, Metastatic colorectal cancer and Head and neck cancer

OVERVIEW



FAMILY

PER ADULT DEPENDANT

R 140

R 175

R 60


15


The Company shall not be liable for hospitalisation, bodily injury, sickness or disease directly or indirectly caused by, related to or in consequence of:01. Medical scheme exclusions unless the event is otherwise insured.02. Hospital account shortfalls, including ward and theatre fees, but not applicable to consumable items.03. Accounts paid from day-to-day benefits or from the savings account of a medical scheme, including consultations in doctors rooms

at a hospital facility, where an insured person has not been admitted, but not applicable to: a) Co-payments that are paid from a medical scheme savings account b) Services under the Casualty Benefit and Trauma Counselling Benefit04. Overall annual hospital limits excluded but not applicable to Hospital Optimiser.05. Medical scheme sub-limit benefits excluded on Base 500, Co-Evolution 500, Comprehensive and Hospital Optimiser.06. Auxiliary services / Allied accounts, but not applicable to: a) Counselling sessions at a registered counsellor or clinical psychologist under the Trauma Counselling Benefit b) In-hospital tariff shortfalls for physiotherapy07. In-hospital dentistry, where the medical scheme does not pay from risk (hospital benefit), including: a) Osseointegrated implants b) Maxillofacial surgery unless due to an accident (proof will be required)08. The Casualty Benefit is not granted where costs incurred are paid by the medical scheme from risk (hospital benefit).09. External prostheses excluded, but not applicable to: a) Internal prostheses on Elite, Senior 500, Corporate Elite and G Force10. Cost of mechanical appliances used during surgical procedures and operations.11. Tariff shortfalls and overall annual limits on MRI and CT scans.12. Co-payments applied as a result of: a) The voluntary use of a non-designated service provider b) Selective / split billing where a co-payment is charged on doctors accounts13. Oncology: a) A total exclusion for any pre-diagnosed cancer is applicable to the Oncology Benefit on Comprehensive, Senior 500, Oncology

Plus and G Force b) Pre-diagnosed cancer is covered provided the insured person is in remission for 5 years either prior to policy inception or during

cover on the Stratum Benefits policy, applicable to the Oncology Benefit on Elite and Corporate Elite c) Base 500, Co-Evolution 500 and Hospital Optimiser do not provide an Oncology Benefit14. Prescription and take home medication.15. Investigations, treatment or surgery for artificial insemination, hormone treatment for infertility or contraception, but not applicable to:

a) Tubal ligation and vasectomy on Comprehensive, Elite and Corporate Elite16. Investigations, treatment or surgery for obesity, the equivalent of cosmetic or reconstructive surgery elated to or in consequence of

cosmetic surgery other than as a result of an event otherwise insured.17. Depression, insanity, emotional illness, mental or mental stress-related conditions.18. Step-down facilities (eg.convalescent home).19. Suicide, attempted suicide or intentional self-injury.20. Drug and alcohol addiction including: a) The taking of any drug or narcotic unless prescribed by and taken in accordance with the instructions of a registered medical

practitioner or any illness caused by the use of alcohol b) An event directly attributable to the insured person having an alcohol content exceeding the recognised legal limit or the insured

person suffering from alcoholism21. Expenses incurred for transport charges or for services rendered whilst being transported in any emergency vehicle, vessel or

aircraft.22. The insured person’s deliberate exposure to exceptional danger except in an attempt to save a human life.23. Active military, police and police reservist activities, whilst on active duty.24. Participation in: a) Civil commotion, labour disturbances, riots, strikes and activities of locked out workers or the insured person’s own criminal act b) International or fighter aviation other than as a passenger, but not applicable to domestic aviation within the borders of South Africa25. Claims will only be considered for payment if the relevant Stratum Benefits policy makes provision for the benefit being claimed for.26. Nuclear weapons, nuclear material, ionizing radiation or contamination by radioactivity from any nuclear fuel or nuclear waste

resulting from the combustion of nuclear fuel. For the purpose of this exception, combustion shall include any self-sustaining process of nuclear fission.

27. Routine physical examinations, procedures of a purely diagnostic nature or any other examination where there is no objective indication of impairment referred to somatic illness or disease in normal health and laboratory, diagnostic or x-ray examinations.

28. Investigative costs incurred by the insured person to assist in the finalisation of a claim.

GENERAL EXCLUSIONS


2015 eng bro final

Documents