2nd Draft recommended by
Committee to the BOT
Ex-gratia, within the context of a medical aid scheme, may be broadly defined as
those circumstances where the medical aid benefit has been exhausted, and the
member makes a special appeal for consideration by the Scheme for assistance in
paying part or the whole amount for which the member may be liable.
It is noteworthy that an ex-gratia award is not an entitlement by the member, as in the
case of bona-fide benefits, and as such is not defined in the table of benefits; it is
rather a special grant provided by the Scheme, on satisfaction of motivation and
other criteria, to assist the most needy and deserving of members.
Ex Gratia Guidelines
This ex-gratia policy is applicable to existing members only.
1. Establish and track a budget.
2. Provide assistance to members for MAJOR, UNFORESEEN medical costs where
members don’t have the means to meet the costs in question. Means assessed by way of
income and expenditure statement submitted to the Committee.
3. Is illness life-threatening / or will requirement drastically improve the quality of life?
4. Is treatment / requirement clinically appropriate?
5. No Ex Gratia applications will be considered for members who have been on the Fund for
less than 1 year.
6. No application will be considered for a requirement of less than R200.
7. Applications will be reviewed considering the extent of current member’s portion (co-
payments), origin of member’s portion, past and present efforts to pay off debt.
8. Benefit categories only considered with clinical motivation: -
Exclusions under the Scheme rules
9. Ex Gratia awards are made on the basis that members cover at least 20% of the cost of
10. Applications for Nursing / Frail Care will only be considered on completion of Nursing
assessment and provision of fee breakdown.
11. Remedial Therapy awards for ongoing treatment will be made on the basis of an initial
assessment report and subsequent follow-up report showing improvement submitted to the
Committee at intervals agreed to by the Committee.
12. General: -
To protect the financial position of the Fund, Ex Gratia benefits are only granted in
exceptional cases. Members are only granted one (in every three year cycle, regardless of
option change) ex-gratia award while on the Scheme, especially in the case of a primary care
A member may not apply for ex-gratia separately for the same procedure.
Costs related to legal fees, tracing fees, etc. which are unrelated to the health costs are
specifically excluded under this policy.
This policy specifically excludes cases with a date of service older than 12 months.
The Committee is conscious that a degree of consistency needs to be introduced into the
process of Ex Gratia awards.
1. Ex-gratia Committee
The Ex-gratia Committee shall be composed of the Fund Officer, three Trustees,
elected by the Board of Trustees, one of whom shall be the chairperson or the
vice-chairperson of the Board of Trustees.
The above Committee shall be assisted by the staff delegated with the
responsibility of administering ex-gratia applications, and shall be led by the Head
of the Claims Department (or as may be decided from time to time dependant on
the operational structure of the Scheme).
2. Ex-Gratia Procedure for benefit exhausted cases
All members finding themselves in a situation of need as a result of having to
contribute out of pocket for medical expenses arising out of their benefits being
depleted may make an application to the Ex-gratia Committee for consideration.
All applicants must complete a standard ex-gratia application form, which shall be
accompanied by the submission of mandatory documentation, these include: -
A copy of the most recent pay-slip / Pension Advice;
A copy of the most recent pay-slip / Pension Advice of spouse or life
partner (where applicable);
Copy of the full specified accounts being claimed against
Doctor / service provider motivation (in cases requiring clinical
In the event of a member being divorced a copy of the divorce
settlement is required.
A consultation with the SAMWUMED Ex-gratia clerk shall be conducted
to ensure that all prescriptions of the procedure has been implemented;
The interview may either take the form of a personal or telephonic
Members are requested to make full disclosure as it relates to the
application procedure – failure to make mandatory disclosure without
reasonable motivation may result in the application being disqualified.
STAFF APPLICATIONS: -
It is specifically recorded that the Claims Manager shall administer all applications for
staff of the scheme, the Union staff and members of the Board of Trustees.
3. Procedure for ex-gratia request relating to Exclusion Items
In addition to the requirements as stated above, the following clinical motivation is
required in cases tabled as a result of exclusions:
Medical cases: Reports and motivation letter from Specialist /
Surgical cases - photo’s, previous history (including scans and
pathology reports), quotes, etc.
4. EX-GRATIA INTERNAL PROCEDURE
The ex-gratia clerk shall conduct a personal interview with the
applicant, either telephonically or personally;
The Ex-Gratia Clerk must ensure that all relevant information is
obtained to complete the request, and shall ensure that all the
requisite checks have been performed before tabling with the
Recommendations Working Group.
In order to compile the case, the Request Form is to be completed
by the Ex-Gratia Clerk with the relevant documentation before the
20th of each month.
Cases requiring clinical assessment shall be forwarded to our
Medical Advisor for their written response.
The Ex-Gratia Clerk will where appropriate seek to obtain lower
costs or possible write-off’s through negotiation with the relevant
All completed Ex-Gratia cases are loaded on the system and
presented to the Recommendations Working Group1 which shall be
composed of: -
Managed Care Co-ordinator
Client Services Co-ordinator
The Recommendations Working Group will make recommendations
on qualifying applications to the Ex-Gratia Committee which are
scheduled monthly for a final decision.
The Ex-Gratia Clerk shall compile all recommendations into
packages for submission to the Ex-Gratia Delegates at least two
working days prior to the meeting date.
The Fund Officer or the Chairperson of the ex-gratia committee
(where the Fund Officer is not available, shall sign off all cases and
the originals shall be filed in a lockable filing cabinet.
Ex-Gratia Clerk will process all approved payments within one
month to the respective service providers / members.
Written response is forwarded to members / Service Providers with
reference to the Ex-Gratia results. These communications must be
rendered in a manner befitting respect, cordiality and
Members are allowed to appeal a decision of the Ex-gratia Committee only in
circumstances where new evidence or situations have come to light preceding an
application being heard. The member must lodge appeals within one month of
receipt of notice from the Scheme.
This group may change from time to time depending on the organisational structure within our
It is herewith recorded that ex-gratia cases contain member information, which is of a
highly confidential nature. Under no circumstances are both staff and Trustees
allowed to discuss cases and/or reveal information outside of the designated
The meeting packs must be placed in sealed envelopes for delivery to Committee
delegates. At the completion of the meeting all packs distributed to the committee
shall be collected and shredded.
Breach of the Scheme’s confidentiality undertaking shall result in disciplinary action.
EX-GRATIA APPLICATION FORM
Ex-gratia payments will be made at the discretion of the Ex-gratia Committee.
An ex-gratia payment is an additional form of payment made over and above the depleted benefits.
Ex-gratia payments may not be considered in advance of any excess in benefit arising.
This application will not be submitted to the committee should any section be incomplete or if the member fails to provide the
Payments will only be made if the Committee is satisfied that extreme hardship would otherwise be imposed upon the member.
Date of application:
Name of Member:
Contact telephone no.(W): (H): (Cell no):
Name of dependant Age
Diagnosis: (or attached doctor’s detailed letter of motivation and photographs where
TO BE COMPLETED BY MEMBER
Member Spouse Total
Total Deductions: Total
NB: AFFIDAVIT REQUIRED IF SPOUSE NOT EMPLOYED
I, the undersigned, hereby certify that the
information stated in this document is true and correct.
Signature: ________________________________ Date: _____________________