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  • pg 1
                                                                                   2nd Draft recommended by
                                                                                     Committee to the BOT


                        EX-GRATIA POLICY


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
         Special Dentistry
         Acute Medicine
         Optical Benefits
         Consultations

9.    Ex Gratia awards are made on the basis that members cover at least 20% of the cost of
      their requirement.

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.

Step One

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
        Member motivation
        Doctor / service provider motivation (in cases requiring clinical
        In the event of a member being divorced a copy of the divorce
         settlement is required.


Step Two

         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.


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.


                 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
                    service providers.
                   All completed Ex-Gratia cases are loaded on the system and
                    presented to the Recommendations Working Group1 which shall be
                    composed of: -
                                                  Ex-gratia Clerk
                                                  Managed Care Co-ordinator
                                                  Client Services Co-ordinator
                                                  Claims manager
                   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

        5. Appeals

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


       6. Confidentiality

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
    required documentation.
   Payments will only be made if the Committee is satisfied that extreme hardship would otherwise be imposed upon the member.

Date of                                                   application:

Plan option:

Name of Member:

Postal Address:

Residential address:


Membership number:
Identity Number:

Contact telephone no.(W):                                         (H):                                   (Cell no):

Name of dependant                                                                                               Age


Diagnosis: (or attached doctor’s detailed letter of motivation and photographs where

Member’s Motivation:

Members Signature


                                    Member                               Spouse          Total
    Gross Salary

   Gross Pension

    Other Income


Total Deductions:                                                    Total

I,                                               the undersigned, hereby certify that the
information stated in this document is true and correct.

Signature: ________________________________ Date: _____________________


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