Boskruin Office Park,
President Fouche Avenue,
Boskruin, 2154
(Entrance Boskruin Village Centre)
P O Box 1555, Fontainebleau,
2032
Telephone: 086 10 11 123
Facsimile: 086 508 2292
POLICY WORDING – CO-PAY COVER
8. WHEN WILL A CLAIM (BENEFIT) BE PAID?
1. INTRODUCTION As soon as we have:
This policy is underwritten by Resolution Underwriters (Pty) Ltd under 8.1. Confirmed your policy;
contract from Resolution Insurance Company Limited. 8.2. Validated your claim;
8.3. All policy conditions have been met;
This is an Accident & Health policy regulated by the Financial Services 8.4. All required documents have been received.
Board under auspices of the Short Term Insurance Act No 53 of 1998.
9. TO WHOM WILL THE POLICY BENEFITS BE PAID?
2. PRODUCT DESCRIPTION
Only the policy holder will have any rights under this policy. The
Co-Pay Cover is a short-term insurance product that will cover co- applicable benefit will be paid directly into your account and our payment
payments ( the excesses imposed in terms of your Medical Scheme to you is subject to the limit and benefit available as stated in the policy
rules) for in-hospital procedures, as well as MRI, CT and Ultrasound documents.
scans done whilst hospitalised.
10. HOW LONG DOES THIS POLICY LAST?
3. LIMITATION
As long as your premiums are paid up to date or until your policy is
The limits of this policy shall be as follows: cancelled by you or by us by giving 30 (thirty) days’ written notice.
3.1. An incident limit of R8000.00 applies per claim.
3.2. Utilisation per beneficiary is limited to no more than three 11. YOUR RESPONSIBILITIES TOWARDS THE POLICY
claims per year
3.3. An overall limit of R50 000.00 per family per annum applies. In order to have cover you need to:
11.1. Pay your premiums.
4. HOW THE POLICY WORKS 11.2. Provide us with true and complete information when you apply for
cover, submit a claim or make changes to your policy. This also
The headlines in this document are for ease of reference only. You must applies when anyone else acts on your behalf.
read the entire clause to understand its full meaning. Check your 11.3. Not admit any fault, nor make any offer or settlement, without our
Schedule of Insurance which, along with any relevant endorsements, written agreement.
explains what cover you have. The benefit amount is not related to the 11.4. Agree to comply with all our reasonable requests.
specific cost of any medical treatment or hospitalisation. 11.5. Use all reasonable care and take all reasonable precautions to
prevent or minimize loss, damage, liability, injury or death.
11.6. Inform us immediately of any changes to your circumstances that
5. WHAT MAKES UP YOUR POLICY OF INSURANCE? may influence, whether we provide cover, the conditions of cover
or the premium we charge.
The Schedule of Insurance, Terms and Conditions, together with any
correspondence sent to you, as well as any verbal agreements we make, 11.6.1. This includes any changes to any information:
form the Policy of Insurance between you and us. Each application must 11.6.1.1. On the Schedule of Insurance or;
be accompanied by a completed application form and questionnaire, 11.6.1.2. In regard to convictions for offences by any person covered
which will form the basis of our contract. under this facility relating to dishonesty, reckless and
negligent driving or driving under the influence.
Please ensure that you are familiar with the contents of all the documents
and that all the detail noted on the Schedule of Insurance is correct in
every respect.
12. INSURANCE POLICY CHANGES
12.1. You have to advise us when your contact details change.
6. WHO IS THE INSURED? 12.2. If you wish to cancel your policy you must do so in writing and
give us 30 days’ notice.
The person/s who are indicated on the policy documents referred to as 12.3. You may make changes to your insurance policy at any time.
“You”, “Your” or “Insured Person” Confirmation of the change will be sent to you.
12.4. We may amend your policy by giving you 30 days’ notice. Notice
can be given verbally, by fax, email or mail to the contact details
7. WHO IS COVERED BY THIS POLICY? on record.
The policyholder and dependants, indicated on the Schedule of
Insurance. A maximum of two adults and three children may be added on 13. YOUR RESPONSIBILITY TOWARDS PREMIUM PAYMENTS
one policy.
Your policy is a monthly Policy and you must pay the monthly premium in
advance on the agreed payment dates as stated on your Schedule of
Insurance. If we do not receive the premium for your Policy on the agreed
payment date we will allow a 15 day period of grace. During this grace
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period, you may deposit your premium into the insurers bank account to 17. COMPLAINT PROCEDURE
maintain your cover.
Any complaint should be directed in writing to the office of the
Insurers Bank Details: Underwriters by means of any of the following:
Resolution Insurance Company Ltd, Postage: Resolution Underwriters (Pty) Ltd
Bank: First National Bank Centurion, P.O. Box 1555
Acc no: 62174071242, Fontainebleau
Branch code: 261550, 2032
Reference: Your Policy Number. Email: complaints@reso-u.co.za
Fax: 086 508 2292
Should a monthly premium not be received a double debit order will be
submitted on the next payment date. If this debit order is also unpaid, the Any complaint received will be acknowledged and responded to, in
Policy will be cancelled as from 24h00 on the last day of the month for writing, within 10 working days.
which premium was received, without the necessity on the part of the
Underwriters of sending or giving any party notice of such fact.
18. JURISDICTION
No benefits are payable if premiums are in arrears on the the date of a
claim. It remains the sole responsibility of you as the insured to ensure This agreement shall be governed, interpreted and construed in
that your premiums is paid and up to date. accordance with the laws of the Republic of South Africa. Any legal
action or proceedings arising out of or in connection with this policy which
is to be instituted in a court of law shall be brought in the High Court of
South Africa and irrevocably submitted to the exclusive jurisdiction of
14. CLAIMS such court.
When you submit a claim, you have certain responsibilities, which are
listed below. If you fail to meet these responsibilities, your claim may be 19. TERRITORIAL LIMITS
rejected.
Cover for this policy is only valid within the borders of the Republic of
14.1. You need to report your claim to us as soon as possible but not South Africa.
later than 30 days after any incident. This includes incidents for
which you do not want to claim but which may result in a claim in
the future. 20. GUARANTEE CLAUSE
14.2. Should you be incapacitated and not be able to make contact,
you may get someone to contact us on your behalf. Guarantee that medical expenses associated with a health event will be
14.3. In order for you to prove a claim, all accounts must be submitted met, may only be offered in the medical scheme environment.
within 90 days after your medical aid paid their portion of the
claim. We shall not be liable for claims where the documentation
is received outside of this period. 21. CONSENT CLAUSE
14.4. Claims can only be assessed for payment once your completed
claim information is received. This information consists of the When you accept this policy you acknowledge:
following:
21.1. The insurance industry must underwrite policies & assess risks
14.4.1. Fully completed and signed claim form; fairly. It must also limit the incidence of fraudulent claims. This
14.4.2. All hospital and doctors accounts received by you; is aimed at protecting the public and limiting premium increases.
14.4.3. A medical aid statement showing all payments made by you or 21.2. The sharing of claims information and underwriting information
your medical aid for the health event. (including credit information) is essential for this reason.
21.3. You hereby waive your right to privacy of any information
provided by you, or on your behalf and related to any policy or
15. DISPUTED CLAIMS claim. You also agree that any information provided can be
verified against any other legitimate source/database used by
After we inform you of our decision on a claim, we will allow you 90 days the Insurance Industry
to make representations to us about our decision. If we do not
compensate you for a claim or a part of it, and you want to challenge our 22. POLICY SPECIFIC EXCLUSIONS
decision, you must do so in writing and outline your reasons for the
dispute. We will provide you with a written response within 30 days. If you We will not compensate you for any illness, condition, disease or injury
do not agree with the outcome of the appeal, you may refer the dispute to or the consequences of treatment of or following or associated with:
the Ombudsman or serve legal process on us within 90 days after the
time we allow for representations on disputed claims. Should you not 22.1. Any claims not authorised or paid by the principal members
enforce these rights, your claim will be deemed prescribed/abandoned. medical scheme.
22.2. Costs incurred for the treatment of Prescribed Minimum
Benefits as this must be paid by your medical scheme in terms
16. FRAUD, MISREPRESENTATION AND DELIBERATE ACTS of the Medical Schemes Act No 131 of 1998. This includes ward
fees, theatre fees, medicines and other hospital expenses.
We will not compensate you for a claim when you or a member of your 22.3. The following conditions within the first twelve (12) months of
household, or anybody who acts on your behalf, deliberately causes a the contract; Myringotomy & Grommets, Adenoidectomy,
loss, damage or injury. All cover under this policy will be forfeited if you Tonsillectomy, Confinement & Hysterectomies, (except where
submit a fraudulent claim, or anyone acts fraudulently on your behalf to malignancy can be proven)
obtain compensation. This policy can be declared null and void if any 22.4. Admission co-payments or deductibles or any deductible not
misrepresentation or non-disclosure is made, by or on your behalf, related specifically to an in-hospital procedure that accrues a
regarding any detail that is material to this insurance in respect of the co-payment in terms of your medical scheme rules.
Insured. Any incorrect information may affect the validity of this contract. 22.5. Claims that exceed the maximum utilisation limit per annum
22.6. Any amounts charged by a Registered Medical Professional
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22.7. Hospital Account Shortfalls. 23.19.3. Participation in professional sport where a fee or benefit in
22.8. Medical scheme exclusions, stated benefit limits/sub limits kind is received, either directly or indirectly for playing or training
or in the work place.
23.20. The cost of treatment for sexually transmitted diseases.
23. GENERAL POLICY EXCLUSIONS 23.21. Any treatment or surgery viewed by the Underwriters as
experimental.
We will not compensate you for any illness, condition, disease or injury
or the consequences of treatment of or following or associated with: 24. STANDARD SHORT TERM POLICY EXCLUSIONS
23.1. An event not covered by this policy. We will not compensate you for any illness, condition, disease or injury
23.2. Any pre-existing condition, disease, disorder or illness, for a or the consequences of treatment of or following or associated with:
minimum of 12 months. This will include any condition for which
an insured person has received treatment by a medical 24.1. Any claim arising directly or indirectly from active involvement in
practitioner before inception of the policy. war, invasion, act of a foreign enemy, hostilities (whether war be
23.3. Claims that occur within the first three (3) months after inception declared or not), civil war, rebellion, revolution, insurrection or
of this policy. This will include any dependants added to the political risk of any kind, or any act of any person acting on
policy after the initial inception date of the policy. behalf of or in connection with any organisation, group or
23.4. Claims for regular or routine medical treatment and advice on activity aimed at overthrowing any government by force or any
an on-going basis for example any chronic condition, deliberate act of terrorism or violence.
chemotherapy, radiation therapy, dialysis or any other regular 24.2. Any riot, strike or public disorder (including civil commotion,
and ongoing treatment. labour disturbances or lock-out) or any act or activity resulting in
23.5. Routine physical examinations or procedures of a purely or calculated to bring about riot, strike or such disorder.
diagnostic nature. This includes, for example any examination, 24.3. Active military duty, police duty, police reservist duty, civil
such as laboratory diagnostic or x-ray examinations that does commotion, labour disturbances, riot, strike or the activities of
not result in a bona fide hospital admission for treatment locked out workers.
purposes. 24.4. The act of any lawfully established authority, police force,
23.6. Medication. security force or any other local, provincial or national body, in
23.7. Any illness, injury or consequence from alcohol, drug or controlling, preventing, suppressing or in any other way dealing
substance intoxication, use or abuse, directly or indirectly, with any event referred to in the clauses above.
traceable to the insured being affected, permanently or 24.5. Compensation in terms of the War Damage Insurance Act no 85
temporarily. Claims may be considered where registered drugs of 1976.
are administered and prescribed by a Registered Medical 24.6. Nuclear weapons or nuclear material, ionising radiation or
Professional. contamination by radioactivity from any nuclear fuel or from any
23.8. Any treatment consequent to alcohol, drug or substance nuclear waste from the combustion of nuclear fuel. For the
addiction. purpose of this exception combustion shall include any self-
23.9. Any psychiatric, psychological condition, emotional or sustaining process of nuclear fission.
nervous conditions including, but not limited to, depression, 24.7. Any loss arising from any contractual liability.
insanity, psychosis, stress-related and affective disorders. 24.8. Any consequential loss or damage whatsoever.
23.10. Suicide, attempted suicide, any intentional or deliberate self- 24.9. Any attempt by you to commit an unlawful act.
injury. 24.10. No benefit payable shall carry interest.
23.11. Self-exposure to danger or risk except in an attempt to save a
human life.
23.12. Any claim which, in the opinion of the Underwriters, is 25. DEFINITIONS AND EXPLANATIONS
associated with any illness, condition or injury for which a
claim has previously been paid out under this policy. No provision or condition may be waived or modified except by an
23.13. Any internal and/or external appliances and prosthesis or endorsement signed by an authorised official of the Underwriters.
implantations, such as braces, crutches, wheelchairs, etc. References throughout the policy to the masculine shall include the
23.14. Any skin/sub-cutaneous tissue disorders, diseases, conditions feminine and the singular shall include the plural where appropriate, and
and illnesses, inclusive of but not limited to, excision and vice versa.
biopsy related to the skin and subcutaneous tissue.
23.15. Elective procedures, elective cosmetic or reconstructive / The following definitions apply throughout the policy:
corrective procedures including any treatment and costs
resulting from these procedures. Except as a result for 25.1. Acute: A condition which is generally unforeseen and is of rapid
treatment for cancer. onset, is severe and treatable, but does not last for a prolonged
23.16. Investigations, treatment or surgery for eating disorders, period and is therefore not chronic.
obesity or weight management, including any consequence of 25.2. Acute or Life-Threatening Health Event/Illness: A specified,
such treatment. acute and unforeseen illness of a life-threatening nature or a
23.17. Any additional fees charged by a Registered Medical traumatic bodily injury which, in the opinion of the
Professional for the management of overweight or underweight Underwriters, requires urgent and immediate admission to
patients with reference to the BMI (Body Mass Index). hospital for diagnosis and treatment.
23.18. Investigations, treatment or surgery related to sterilisation, 25.3. Diagnostic: A procedure or test which is performed to find out
infertility, artificial insemination, hormone treatment for what is wrong with a patient. Diagnostic procedures do not aim
infertility, contraception or any other form of assisted to treat or cure a condition but is informational and exploratory
reproduction. in nature.
23.19. Any illness, injury or condition resulting from, consequent to or 25.4. Excess: The first portion of any claim payable by you before
associated with: cover commences.
23.19.1. Participation in any form of race or speed test (other than on 25.5. Hazardous Sport: The following activities are considered to be
foot or not involving any mechanically propelled vehicles or hazardous sports: Para gliding - Hang-gliding – Motor boat
crafts). racing - Motor racing - Motor cycle racing – Skiing - Rugby -
23.19.2. Participation in a sport or hobby that is defined by Underwriters Rally driving - Any other form of racing or speed trial. The
as hazardous or dangerous except for scholars taking part in Underwriters reserves the right to add to this list from time to
school activities. time.
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25.6. In-Hospital / Hospitalisation: Confinement in a private hospital
as a resident in-patient under the professional care of a
Registered Medical Professional as defined and approved by
the Underwriters.
25.7. Injury: An injury sustained in an unforeseen future event,
caused solely and directly by violent, accidental, external and
visible means independent of and untraceable to any other
cause.
25.8. In-patient: A patient who is admitted as a resident to the
hospital as an in-patient and who spends time in a hospital
ward admitted as such.
25.9. Insurance Company / Insurer: Resolution Insurance Company
Limited, the Insurer of this policy referred to as “us”.
25.10. Pre-existing conditions: Any illness, injury, condition or
disorder which existed before you took out this policy.
25.11. Prescribed: A claim that is deemed prescribed in line with the
Prescription Act No 68 of 1969.
25.12. Professional sport: This is a sport where a fee or benefit in
kind is received either directly or indirectly, for playing or
training.
25.13. Psychiatric or psychological condition: Any kind of mental
illness and disability. This includes all forms of major affective
disorders, anxiety disorders, psychiatric conditions and all other
mental disorders as outlined in DSM IV (a manual outlining the
diagnosis of all psychological and psychiatric conditions).
25.14. Registered Medical Professional: A person legally licensed
and duly qualified to practice medicine and surgery (other than
the Insured or a member of the Insured’s immediate family).
This includes people legally licensed, duly qualified and
registered in the Specialist Register of the Health Professional
Board of the Republic of South Africa and recognised as such
by the Underwriters.
25.15. Resolution Underwriters (Pty) Ltd / Underwriter(s): Any
person who or which issues a financial product to clients in the
form of a short-term Insurance policy as defined in the Short-
Term Insurance Act No 53 of 1998 by virtue of an authority,
approval or right granted to such person in terms of a written
agreement entered into by such person with a Short-Term
Insurer, authorised to carry on Short-Term Insurance business
in the Republic of South Africa. An Underwriting Manager’s
sole remuneration is derived from such activities and such
person is deemed to be an agent of the Short-Term Insurer. The
acts of an Underwriting Manager shall in all respects be and are
fully binding upon the Short-Term Insurer. Premiums received
by an Underwriting Manager on behalf of the Short-Term
Insurer shall irrevocably be deemed to have been received by
the Short-Term Insurer.
25.16. Scholar: An insured that is attending primary or secondary
school. This definition specifically excludes any student or
attendant of a tertiary institution.
25.17. Treatment: Services provided to a patient, by a Registered
Medical Professional approved by the Underwriters, for
acute, life-threatening medical condition.
25.18. Medical Aid Rate: The reimbursement rate paid by the Medical
Aid based on the generally accepted 100% Medical Aid
benefits. In the event of a dispute this rate will be the 2006
National Health Reference Price List rate.
Effective – 01 July 2011, please note that this policy wording
replaces any previous policy wording regarding this policy.
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