ANNEXURE D: General exclusions

(with due regard to the Prescribed Minimum Benefits)

All medical schemes have a list of services and products that they will not pay for. The Scheme’s exclusions are split into general and dental exclusions to make it easy for you to determine what will not be covered by the Scheme.

  • Search and rescue
  • Complications or the direct and indirect expenses that arise from receiving treatment that is excluded
  • Purchase of patent food, including baby food, 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, and anti-smoking treatment and substances
  • Experimental, unproven or unregistered treatment or practices
  • Expenses arising from, or connected to, misconduct, other operations/procedures of choice, other than circumcisions, and preventive procedures
  • Treatment or operations for purely cosmetic purposes, obesity, including Pickwickian syndrome, infertility and artificial insemination, as described in the Human Tissue Act, Act 65 of 1983. Except for PMB conditions/treatment, consultations, investigations, examinations, the treatment of infertility and the artificial insemination is an exclusion.
  • Treatment for Alzheimer’s disease
  • Frail care and sickbay care in retirement villages, old age homes 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: the Scheme will cover medical treatment rendered in the Southern African Development Community only; treatment will be paid in accordance with the Scheme’s 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 or she takes out additional cover, as this will not be covered by the Scheme
  • Reports, examinations and 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 and sunblock
  • Accounts for appointments not kept by members
  • All complementary medicines, including vitamins that can be obtained without a prescription
  • Telephonic consultations with medical practitioners
  • Aphrodisiacs
  • Cochlear implants
  • Ante- and post-natal exercises or classes, or mother-craft and breast-feeding instructions, unless it forms part of a birth management programme
  • Costs that are higher than the annual maximum benefit due to the member and his or her dependants in a given calendar year
  • Contact lens cleaning materials and spectacle/contact lens cases
  • Experimental, unproven or unregistered treatment or practices
  • Medical treatment in a research environment
  • Maintenance is only covered for hearing aids as per individual plan benefit annexures
  • Skin lesions, except where cancer is proven by submission of histology results
  • No benefit will be paid for sunglasses or lenses for sunglasses
  • Sleep clinics and holidays for recuperative purposes
  • Operations, medicines, treatment and procedures for gender alteration or realignment 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 benefitsunless complications qualify as a prescribed minimum benefit
  • Any condition that arises from the deliberate refusal of medical treatment, except in the case of terminally ill patients
  • Reversal of vasectomies/sterilisation
  • Pain relief machines
  • Hyperbaric oxygen therapy
  • Professional speed contests or professional speed trials (professional is defined as the beneficiary’s main form of income is derived from taking part in these contests)
  • Prophylactic treatment precribed for malaria by a medical practioner