Hospital Insurance Plan
You want peace of mind and guarantees that you will be able to take care of the unexpected. Essential Med’s Hospital Plan gives you all this and more – our involved and caring assistance, when you and your loved ones need it most.
Illness Hospitalisation / Maternity Benefits
The Illness Benefit ensures that you aren’t left with huge bills after a visit to hospital. The Plan will pay a daily contribution per illness, per person per overnight stay in hospital, up to 21 days per illness event.
The Maternity Benefit will pay a daily contribution based on the number of days spent in hospital for the delivery – irrespective of the procedures performed.
An illness benefit of R15 500 is payable after the first three days in hospital, and is made up as follows:
- R6 500 payable after the first day in hospital
- R4 500 payable after the second day in hospital
- R4 500 payable after the third day in hospital
- Thereafter a further benefit of R1 500 is payable per day, up to a further 18 days per illness, per person, while in hospital
Illness Events
An insured client may have many illness events in a year, however, benefits are only payable if the insured client is hospitalised. If an insured client is admitted to hospital for 5 days, and then a few weeks later is readmitted for the same illness, the insured would only have benefits for a further 16 hospital days. However, if the insured client was readmitted for a different illness, they would have 21 days of cover available for the new illness. Should an insured client be admitted to hospital for the full insured period (i.e. 21 days), they may not be readmitted for the same illness, unless 6 months have elapsed between the first and second diagnosis.
How it works:
Should an insured client be admitted for an illness for 5 days in hospital, the payment will be as follows:
- 1st 24-hour day: R6 500
- 2nd 24-hour day: R4 500
- 3rd 24-hour day: R4 500
- 4th 24-hour day: R1 500
- 5th 24-hour day: R1 500
- Total payout: R18 500
Please note that if the hospital/procedure costs exceed these limits, the insured client is responsible for paying the difference. No benefit is payable should a person be hospitalised for less than 24 hours.
The 1st and 2nd day benefits are payable once per each 21-day illness period insured. For example: a client who is admitted to hospital for 5 days will not receive the same 1st and 2nd day benefit if they are readmitted for the same illness within a 6-month period. The benefit will only be payable if they are admitted to hospital for a different illness.
Accident Hospitalisation Benefit
Accident Hospitalisation Benefit pays medical expenses of up to R125 000 per incident, per single person; and up to R250 000 per incident, per family. An insured person may have multiple accident events in a single year – for each event, the policy will pay out up to the stated sum of money specified in the policy document (subject to an excess of R500 per event).
How it works:
For accident expenses, the policy pays out in units of R200 for every R190 of medical expenses incurred by the insured person. This means that the policy will always pay out slightly more than the actual expense, provided the expense does not exceed the Accident limit stated in the policy. This benefit is available immediately (i.e. on inception of your policy).
Dread Disease Benefit
The Dread Disease Benefit pays a lump sum of R185 000 in daily instalments of R9 000 (upon diagnosis), once per single person or family per year. It covers heart attacks, coronary heart disease, cancer, strokes, brain tumours, kidney failure, organ transplants, paraplegia and blindness.
Explanations:
The Dread Disease Benefit is payable once per year. For example: in the unlikely event of two (2) family members being diagnosed with a Dread Disease in the same year, only one (1) benefit up to R185 000 is payable.
Once an insured client is diagnosed and has been paid out for a specific dread disease, the insured will not be eligible for another payout for the same dread disease should it recur in any subsequent year.
Accident Permanent Disability Benefit
R250 000 is payable in respect of the permanent disability of the principal client only.
HIV/Aids Protection Benefit
Each client covered under the plan will receive assistance in the event of accidental exposure to HIV/Aids. The incident resulting in possible exposure to HIV must be reported to our helpline within 72 hours. An insured client can use this benefit twice (2 times) per year, subject to a maximum of two (2) visits per family, per year.
Death Benefit
A Death Benefit of R10 000 is payable to the named beneficiary/s following the death of the principal insured client.
Other Important Facts
- Please note that this is not a Medical Scheme; this is a Stated Benefit Insurance Hospital Plan.
- If you already have Insurance or Medical Aid your first claim would be against your Insurer or Medical Aid Scheme. Essential Med shall be liable to make good only the rateable proportion of the amount payable by or to on behalf of your claim.
- You may choose to use most hospitals.
- The Accident Benefits are subject to an excess of R500 for each claim.
- The Illness Benefits are subject to a 90-day waiting period.
- Dread Disease benefits are subject to a 90 day waiting period from date of policy inception.
- The HIV/Aids Benefit is not applicable if you have tested positive for HIV/Aids prior to joining Essential Med.
- You will enjoy cover while you pay your monthly premium, or until you reach 65 years of age.
- All stated benefits are paid to the insured member.
- For further details please refer to your policy wording.
- You and your spouse have to be younger than 55 years of age when you join the plan.
- A 12-month exclusion period is applicable in respect of pregnancy i.e. a person has to be on the plan for 12 consecutive months before benefits become applicable in respect of childbirth.
- Exclusions and waiting periods may apply for known pre-existing conditions.
The hospital plan is underwritten by Sanlam Developing Markets Limited.
