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Policy Wording

The Company: Western National Insurance Company Limited
Registration no. 2005/17349/06
Insured Person: The member of the Medical Scheme who has elected to participate in the Western National Insurance Company GapCover product
Postal Address: PO Box 5881, Tyger Valley, 7536
Territorial Limits: Republic of South Africa
Premium: As indicated by the Policy Schedule
Premium Increase: Premiums may be reviewed on an annual basis.

In consideration of and conditional upon the prior payment of the premium by or on behalf of the Insured and the receipt thereof by or on behalf of Western National Insurance Company Limited (the Company) before the inception date or renewal date (as the case may be) and subject to the terms, exceptions, conditions and provisions of the Policy the Company agrees to pay the principal Insured Person for an Insured Event occurring during the period of insurance up to the limit of indemnity stated for the Insured Person and the benefit as stated in the Policy

To qualify for this policy's benefits, the Insured Person(s) must be a member or dependant of a medical scheme in terms of the Medical Schemes Act

The Policy, its schedules and annexures/endorsements shall be read together as one contract. It is imperative to ensure you are familiar with the contents of all the documents and that all details are correct.

BENEFITS:
The Company will (subject to the limits shown below) pay the cash value of the accrued benefit resulting from an Insured Event
Please Note: Benefits are applicable only to the relevant chosen option.

Insured Person as stated in the Schedule by the Administrator
The Insured, spouse and each dependent child
Maximum benefit payable per Period of Insurance

GapCover
5 Times the Scheme Tariff limited to the maximum amount as per the Schedule.

CoPay Cover
An event limit of R10 000 (ten thousand rand) limited to no more than 3 (three) claims events per beneficiary per annum. Overall annual limit of R50 000 (fifty thousand rand) per family.

BENEFITS PAYABLE:
GapCover and CoPay Cover are short-term insurance stated benefit policies under the Short-term Insurance Act 53 of 1998. The benefit amount payable is not related to any specific cost of medical treatment or hospitalisation.

GapCover benefits are payable to the Insured Person based on the costs charged per insured event in excess of the Scheme Tariff and limited to the maximum benefit payable per Period of Insurance.

Benefits are related solely to associated services rendered in a hospital, unattached operating theatre or day clinic, provided that normal benefit limits have not been exceeded.

CoPay Cover is a short-term insurance stated benefit product that will cover co-payments (the excesses imposed in terms of your Medical Scheme Rules) for procedures performed on you as an in-patient or as an out-patient, as well as MRI, CT and Ultrasound Scans.

General Conditions

PREMIUM PAYMENTS:
All premiums are payable monthly on the selected debit-order date. The period of grace allowed for non-payment of premiums is 21 days after the month in which the premium was due. If three consecutive premiums are not paid, the Policy will lapse. If premiums, in whole or in part, are in arrears no claim will be payable.

FRAUD, MISREPRESENTATION AND DELIBERATE ACTS:
The Company will not compensate the Insured for a claim when the Insured or a member of the Insured’s household, or anybody who acts on the Insured’s behalf, deliberately causes a loss, damage or injury. All cover under this Policy will be forfeited if the Insured submits a fraudulent claim, or anyone acts fraudulently on the Insured’s behalf to obtain compensation. This Policy may be declared null and void if any misrepresentation is made by or on the Insured’s behalf regarding any detail that is material to this insurance in respect of the Insured. Any incorrect information may affect the validity of this contract.

DEFINITIONS:
In this Policy all words and expressions signifying the singular shall include the plural and vice versa. The following words and expressions shall have the following meanings:

Insured Event An insured person stated in the Schedule being hospitalised for any reason not otherwise excluded in this Policy.
Accident Bodily injury caused by violent accidental and external physical means.
Admission Fee The fixed amount you have to pay in terms of your Medical Scheme Rules when you are admitted to hospital as an in-patient.
Application Form The form the Principal Member completes, and which is the basis for the selection of benefits
Commencement Date The first day of the calendar month for which a premium has been paid by or for the Insured Person.
Entry Date The Commencement Date and/or the first day of any month thereafter
Expiry Date The notified date of cancellation of benefits by either the Insured or his legal representative.
Administrator As contracted by the Company
Member Any one of Principal Member, Spouse or Child subject to the basis of selection of benefits.
Insured Person or Principal Member The person who is to be insured under this Policy and whose benefit(s) has/have not expired in terms of the Expiry Date.
Scheme The registered Medical Scheme of which the Insured is a member.
Schedule The document provided by the Administrator to the Insured on the Commencement Date.
Maximum Benefit Insured The amount insured in respect of a Principal Member, Additional Member, Spouse or Child as stated in the Schedule.
Age at entry Maximum age at entry for an adult is 70, and benefits will continue as long as the Policy is valid.
Child(ren) Eligible child means a biological child, legally adopted child or stepchild of a principal Insured Person who is registered as their child dependant on a Medical Scheme and who is not already insured under the Policy or any other insurance issued by the Company providing similar cover. As soon as any eligible child cease to meet the definitions above, they will no longer be eligible for cover under this Policy as a child dependant and any benefits under this policy shall cease.
Spouse

The legal or common-law husband/wife of a Principal Member or such person residing with the member, and who is normally regarded by the community as the Principal Member’s husband/wife.

Should a principal Insured Person have more than one spouse who could qualify as an eligible spouse, that principal Insured Person must make an irrevocable nomination of one eligible spouse to whom the benefits provided by this Policy are to apply. No benefits will be paid in respect of an eligible spouse if more than one person qualifies as such and no nomination has been made by the principal Insured Person.

On the death of the principal Insured Person the cover of the eligible spouse under this Policy may be continued should such spouse elect to do so within sixty (60) days of the death of the principal Insured Person.

Pre-Existing Conditions

  1. Any medical or dental condition for which an Insured Person received medical advice, diagnosis, surgery, radio or chemotherapy, treatment or care; including the use of prescription medication, from a Licensed Medical Practitioner during a 2 year period prior to the inception date of that Insured Person, unless such a condition was directly attributable to an Accident (as defined).
  2. Any condition which arises from signs or symptoms that the insured is currently aware of, but:
    • have not yet sought a medical opinion regarding the cause
    • is currently under investigation to define a diagnosis
    • the insured is awaiting specialist opinion further medical or specialist opinion
  3. All conditions related to any pre-existing condition

 

Conditions

CLAIMS
(which shall be paid to the Insured or his personal legal representative)

  1. following an Insured Event the Insured shall at his own expense
    1. notify the Company as soon as is practicable
    2. supply in writing any such proof, medical evidence or other information as the Company may reasonably request
  2. no claim shall be payable if the Company is not notified of an Insured Event within three months of the Medical Scheme’s short payment or within three months of the termination of this Policy, whichever occurs first
  3. no claim shall be payable if the Policy and Medical Scheme conditions/requirements have not been met.

THE CORRECTNESS OF STATEMENTS MADE TO THE COMPANY

  1. The Company relies on the truth, completeness and correctness of all statements submitted. If the benefits granted or the reinstatement thereof has been obtained through any misrepresentation or concealment, this Policy shall be void and monies paid in respect thereof shall be forfeited.
  2. Should any benefits have been paid out on the basis of the information provided by the Scheme to the Company and such information subsequently proves to be incorrect in any material respect, the Company shall have the right to take such steps as may be required to put it in the position it would have been in if the correct information had been provided in the first instance.

LIABILITY OF THE COMPANY
The liability of the Company, unless otherwise agreed with the Insured, shall be limited to the benefits actually purchased by the premiums received according to the rates in force in respect of benefits agreed on under this Policy at the time of purchase.

DEPENDANT REGISTRATION
The Administrator must be informed of all additional dependants within 30 days of the occurrence by submitting the latest medical scheme membership certificate. Cover for dependants added after the policy start date will be subject to waiting periods applicable to this policy. Underwriting will not be applied to Newborn babies, provided that they are registered within thirty (30) days after birth. Should the notification to the Administrator be done more than 30 days after the occurrence, the inception date on the policy will be from the 1st of the following month after the notification has been received.

TERMINATION OR ALTERATION
Cover shall cease:

  1. At 24:00 on the last day of the month for which the last premium was paid.
  2. If three consecutive premiums are not paid when due or three consecutive premium debits are dishonoured, unless the Insured can prove to the satisfaction of the Company that this was an error by his paying agent.
  3. in respect of dependants, when terminated from Medical Scheme, provided the Administrator is notified within 30 days of the occurrence by submitting the latest medical scheme membership certificate.
  4. Upon written notification that the Insured ceases membership of a Medical Scheme registered under the Medical Schemes Act No. 131 of 1998.
  5. Once the Insured (or his legal representative) has given one month’s written notice to terminate this Policy, or once the Company has provided at least one month’s written notice to the Insured of any such alteration or termination. Upon receipt of this notice, all the benefits will be cancelled forthwith and all subsequent premiums paid will be refunded.

Premiums will be refunded only for a maximum of three (3) months if approved by the insurer.

Cover may be altered by the Company upon giving at least one month’s written notice of any possible changes to the Policy. The Administrator does not accept responsibility if an email address, postal address or contact numbers are not updated by the policy holder.

JURISDICTION
The Policy shall be subject to the laws of the Republic of South Africa whose courts shall have sole jurisdiction to the exclusion of the courts of any other country

Where payment is to be made to or by the Company it shall be made in the currency of the Republic of South Africa. Cover for this Policy is only valid within the borders of the Republic of South Africa.

STANDARD SHORT-TERM INSURANCE EXCLUSIONS
The Company shall not be liable for hospitalisation for bodily injury, sickness or disease directly or indirectly caused by related to or in consequence of:

  • Nuclear weapons or nuclear material or by ionising radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel. For the purpose of this exception combustion shall include any self-sustaining process of nuclear fission.
  • Participation in active military duty, police reservist duty, civil commotion, labour disturbances, riot, strike or the activities of locked-out workers.

STANDARD UNDERWRITING APPLICABLE ON THIS POLICY

  • No benefits are payable during the first three months of cover unless the Insured Event that required hospitalisation was caused by an accident that occurred after the commencement date of cover
  • Pre-Existing Conditions excluded for a minimum period of twelve (12) months from date of inception:
  1. Any medical or dental condition for which an Insured Person received medical advice, diagnosis, surgery, radio or chemo therapy, treatment or care; including the use of prescription medication, from a Licensed Medical Practitioner during a 2 year period prior to the inception date of that Insured Person, unless such a condition was directly attributable to an Accident (as defined).
  2. Any condition which arises from signs or symptoms that the insured is currently aware of, but:
    • have not sought a medical opinion regarding the cause
    • is currently under investigation to define a diagnosis
    • the insured is awaiting further medical or specialist opinion
  3. All conditions related to any pre-existing condition
  4. Underwriting can be imposed at claim stage

WAITING PERIODS APPLICABLE TO THIS POLICY

  • Hysterectomies will not be covered within the first twelve (12) months of the female’s contract except where malignancy can be proven.
  • Pregnancy, Childbirth, Myringotomy, Grommets, Adenoidectomy and Tonsillectomy will not be covered during the first twelve (12) months of the Insured’s contract.

PERMANENT EXCLUSIONS AND LIMITATIONS TO THIS POLICY
The liability of the Company, unless otherwise agreed with the Insured, shall be limited to the benefits actually purchased by the premiums received according to the rates in force in respect of benefits agreed on under this Policy at the time of purchase.

  1. Investigations, treatment or surgery for eating disorders, obesity or weight management, including cosmetic surgery and any consequence of such treatment, as well as any additional fees charged by a Registered Medical Professional for the management of the abovementioned conditions with reference to the Body Mass Index (BMI).
  2. Suicide, attempted suicide or intentional self-injury.
  3. Drug addiction.
  4. The taking of any drug or narcotic unless prescribed by and taken in accordance with the instructions of a Registered Medical Practitioner (other than the Insured Person) or any illness caused by the use of alcohol.
  5. An event directly attributable to the Insured Person having an alcohol content exceeding eighty (80) milligrams per one hundred (100) millilitres of blood or the Insured Person suffering from alcoholism.
  6. Aviation other than as a passenger.
  7. Any form of race or speed test (other than on foot or involving any non-mechanically propelled vehicle, vessel, craft or aircraft).
  8. Any claims not covered by the principal Insured Person’s Medical Scheme.
  9. Medication, drugs, prescriptions, consumables and equipment used during a procedure.
  10. Any internal and/or external appliances, prostheses, implantations or devices, such as braces, crutches, pacemakers, artificial joints, etc.
  11. All auxiliary services such as physiotherapy, podiatry, occupational therapy, dieticians, etc.
  12. Optometry such as spectacles, lenses and contact lenses, etc.
  13. Medical Scheme exclusions, stated benefit limits/sub-limits, copayments (unless CoPay option has been added to the Policy). Copayments that occur when the member chooses not to use the medical scheme’s designated service provider (DSP) are excluded.
  14. Hazardous sport and aviation other than as a passenger. The following activities are considered to be hazardous sports, regardless of whether the beneficiary takes part in an amateur or professional capacity:
    1. Paragliding
    2. Hang-gliding
    3. Motorboat racing
    4. Motor racing
    5. Motorcycle racing'
    6. Skiing
    7. Rugby (Professional)
    8. Rally driving
    9. Any other form of racing or speed trial
    The Underwriters reserve the right to add to this list from time to time.
  15. Routine physical examinations or procedures of a purely diagnostic nature. These include, for example, any examination, such as laboratory diagnostic or x-ray examination that does not result in a bona fide hospitalisation for treatment purposes.
  16. Cost of any treatment that is recoverable from another party.
  17. Psychological or psychiatric conditions such as depression, insanity, mental or mental stress-related conditions.
  18. Service rendered by persons not registered with the SA Medical and Dental Council, the SA Nursing Council or the Health Professions Council of South Africa.
  19. In illness of a protracted nature the Company may nominate a specialist of its choice in consultation with the attending practitioner.
  20. Out-patient facility fees.
  21. Prescribed Minimum Benefits (PMB): A set of benefits as defined in the Medical Schemes Act 131 of 1998 with Regulations, which ensures all Scheme members have access to certain minimum health benefits, regardless of their Medical Scheme option. This includes a requirement for Medical Schemes to pay the full cost of diagnosis and treatments of a list of 270 medical conditions, provided that you follow the Scheme Rules and make use of your Designated Service Provider (DSP).
  22. No claim under R100.00 will be honoured.
  23. Maxillofacial, dentistry and/or dental treatment in and out of hospital is excluded for GapCover and CoPay Cover; however, a maximum benefit of R3 000 per family per annum for shortfalls, and a maximum benefit of R3 000 per family per annum for copayments, are allowed on the removal of impacted wisdom teeth in hospital, and in-patient dental procedures for children up to age 7.
  24. Bionic ear implants, breast reduction and reconstruction and nasal reconstruction are limited to R1 000.00 per case.
  25. Investigations, treatment or surgery related to insertion of intrauterine devices, contraception, infertility, artificial insemination and hormone treatment for infertility or any other form of assisted reproduction will be excluded; however, treatment or surgery related to sterilisation or vasectomy will be covered.

Effective 01 July 2015. Please note that this policy wording replaces any previous policy wording regarding this product.