Scheme Exclusions

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.

General exclusions

  • 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

Note: preventive procedures do not include the following:

  • preventive influenza measures prescribed by a medical practitioner
  • Hibtiter and Tetratiter vaccinations
  • vaccinations, as approved by the Department of Health
  • preventive malaria measures prescribed by a medical practitioner
  • 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
  • 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
  • Cost of repairs, maintenance, parts or accessories of external appliances
  • 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)

Dental exclusions

  • The cost of general dentistry performed in hospital
  • The cost of gold, metal or other inlays in a denture or crown
  • Fee for after-hours visits that the Scheme considers as convenience visits
  • Bleaching of vital teeth
  • Unregistered items and items listed as ‘by agreement’ or ‘not applicable’ in the tariff code listing
  • Lingual orthodontic treatment
  • Services that deviate from the available guidelines of the Department of Health and that are deemed to be excluded from benefits after evaluation of the available information
  • Gum guards for sport purposes
  • Laboratory costs that, according to the Scheme’s norms and judgement, seem to be above the general cost claimed by other dental service providers and laboratories treating similar conditions
  • Services or procedures that are regarded by the Scheme as cosmetic, when alternative functional services exist (in which case the benefit will be excluded entirely or in part and/or paid in accordance with the cost of such functional alternative service)
  • The cost of a written report compiled by a dental practitioner or specialist for which prior authorisation was not granted by the Scheme

Any treatment listed below:

  1. Any specialised treatment listed in the Scheme rules as requiring pre-authorisation where no pre-authorisation was obtained
  2. Orthodontic treatment for dependants older than 18 years old
  3. Orthodontic procedures, including retainers, are limited to once in a lifetime
  4. Electrognathographic recordings and other such electronic analysis
  5. Metal base to full dentures, including the laboratory cost
  6. Soft base to new dentures
  7. Diagnostic dentures
  8. Pontiacs on second molars
  9. Provisional and emergency crowns and associated laboratory cost
  10. Ozone therapy
  11. Resin bonding for restorations charged as separate procedure
  12. Dental bleaching and porcelain veneers
  13. Laboratory-fabricated crowns and root canal treatment on primary teeth
  14. Gingivectomies
  15. Periodontal flap surgery and tissue grafting
  16. surgical tooth exposure for orthodontic reason
  17. in-hospital surgical tooth exposure that was not pre-authorised as part of an orthodontic treatment plan
  18. orthodontic re-treatment or unauthorised initial treatment commencing on an orthodontic treatment plan
  19. orthognathic (jaw correction) surgery and related hospital costs
  20. sinus lift
  21. bone augmentation
  22. bone and other tissue regeneration procedures; cost of bone regeneration material (including laboratory costs)
  23. multiple hospital admissions for extensive conservative (basic) dentistry in young children (only one admission per child every  24 months)
  24. laboratory delivery fees
  25. cost of mineral trioxide
  26. cost of gold, precious metal, semi-precious metal and platinum foil
  27. in-hospital treatment for procedure not considered as invasive based on fear and anxiety in adults
  28. surgery associated with dental implants, grafts, etc.
  29. in-hospital dental implants, dentectomies, and apicectomies
  30. mouth guards and snoring appliances and the associated laboratory cost (including material)
  31. oral hygiene instructions; PerioChip