ANNEXURE D: General exclusions
(with due regard to the Prescribed Minimum Benefits)
Unless otherwise decided by the Board of Trustees, costs and or expenses incurred by the member and or any dependant in connection with any of the following will not be paid :-
- Search and rescue
- Complications or the direct and indirect expenses that arise from treatment in these exclusions
- Experimental, unproven or unregistered treatments or practices
- Pain relief machines
- Hyperbaric oxygen therapy
Purchase of patent foods including baby foods, patent medicines, preparations of the type generally promoted to the public to increase consumption, cosmetics, proprietary preparations, biological substances, contraceptives and slimming preparations, medicines advertised to the public and domestic-, biochemical-, or herbal remedies except when prescribed by a homeopath, anti-smoking treatment and substances.
Treatments or operations for purely cosmetic purposes, obesity including pickwickian syndrome, infertility and artificial insemination as described by The Human Tissue Act, Act 65 of 1983.
Expenses arising from or connected with misconduct, other operations/ procedures of choice other than circumcisions and preventive procedures.
"Preventive care" does not include the following: -
- Preventive influenza measures prescribed by a medical practitioner;
- Hibtiter and Tetratiter vaccinations;
- Vaccinations as approved by the Department of Health;
- Preventative Malaria measures prescribed by a medical practitioner.
Treatment for Alzheimer's disease.
Frail care and sickbay care in retirement villages, old age home or private residences.
Treatment rendered by naturopaths and any other person not registered with the South African Medical and Dental Council as a medical auxiliary or registered with the South African Nursing Council as a registered nurse.
Medical cover outside the borders of South Africa: - Moto Health Care will cover medical treatment rendered in the SADC regions only, treatment will be paid in accordance with the Moto Health Care prescribed rate and the scheme will apply the South African currency exchange rate applicable on the date the treatment was rendered.
Members travelling outside the borders of South Africa to participate in non – professional or professional sports must ensure he/she takes out additional cover as this will not be covered by Moto Health Care.
No benefit will be paid for sunglasses or lenses for sunglasses.
Sleep clinics and holidays for recuperative purposes.
Reports, examinations or tests requested for emigration, immigration, visas, insurance policies, employment, scholastic abilities’ readiness for school, admission to school and universities, court medical reports, muscle-function tests for fitness, fitness examinations and tests, adoption of children and retirement because of ill-health.
All costs of whatsoever nature incurred for treatment of sickness conditions or injuries sustained by a member or a dependant and for which any other party is liable. The member is however entitled to such benefits as would have applied under normal conditions, provided that on receipt of payment in respect of medical expenses, the member will reimburse the Scheme any money paid out in respect of this benefit by the Scheme
Breathing exercises for chronic airway diseases.
Toiletries, cleansing agents, anabolic steroids, sun-block.
Account for appointments not kept by members.
All complementary medicines including vitamins that can be obtained without a prescription.
Telephonic consultations with medical practitioners.
Ante- and post- natal exercises or classes, or mother-craft and breast-feeding instructions unless it forms part of the Maternity Management Program.
Costs, which are more than the annual maximum benefit due to the member and his/her dependants in a given medical year.
Contact lens cleaning materials and spectacle/contact lens cases.
Experimental, unproven or unregistered treatment or practices.
Medical treatment in a research environment.
Operations, medicines, treatment and procedures for gender alteration or re- alignment for personal reasons and not directly caused by or related to illness, accident or disease. Furthermore, any medical condition or complication that arises at a later stage, whether directly or indirectly, as a result of the original excluded treatment is similarly excluded from benefits, unless complications qualify as a PMB.
Drugs, where there is no evidence to prove efficacy or cost effectiveness for chronic conditions.
Cost of repairs, maintenance, parts or accessories of external appliances.
Skin lesions, except where cancer is proven by submission of histology results.
Any condition which arises from the deliberate refusal of medical treatment except in cases of terminally ill patients
Reversal of vasectomies/sterilisation.
Professional speed contests or professional speed trials (professional defined as where the beneficiary’s main form of income is derived from partaking in these contests), subject to PMBs