The Illness Hospitalisation Benefit Explained

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Private Hospital Cover for Illnesses & Planned Procedures

3 month waiting period
3 Benefit Levels
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Optional Benefit
Nationwide Network

Cover private hospital costs when you are admitted for an illness or planned procedure. Choose the benefit that pays daily amounts for up to 21 days in hospital with additional cover for stated conditions like hernia, kidney stones and appendectomy.

Stated conditions are covered up to their limits regardless of the number of days in hospital.

The Hospital Plan has flexible cover for all of this and more.

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Choose Your Level of Cover

Flexible levels of cover mean you get to choose your benefit limits to suit your needs and budget.

Level 1

  • Admission Days
  • Up to R6,500 for 1st day
  • Up to R4,500 for 2nd day
  • Up to R4,500 for 3rd day
  • Up to R1,500 per day for the remaining 18 days
  • Up to R42,500 available per event

Level 2

  • Admission Days
  • Up to R10,000 for 1st day
  • Up to R6,500 for 2nd day
  • Up to R5,000 for 3rd day
  • Up to R1,500 per day for the remaining 18 days
  • Up to R48,500 available per event

Level 3

  • All Level 2 benefits included
  • Plus Stated Conditions
  • Hernia: R20,000
  • Appendectomy: R35,000
  • Gallbladder/Kidney Stones: R35,000
  • Miscarriage: R10,000
  • Hysterectomy: R45,000

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What is Covered?

The Illness Hospitalisation benefit covers you for hospital costs related to an illness.

There needs to be a diagnosis for procedures to be covered and they must be medically necessary. Elective surgery and admission for diagnostic purposes is not covered under this benefit.

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How do Admission Days work?

There is up to R48,500 available to pay for hospital costs with specific amounts available per admission day. What this means is that there are limits available per day spent in hospital up to a maximum of 21 days.

Each admission day is calculated as 24 consecutive hours spent in hospital and each admission day follows on from the previous day.

For example, if you are admitted into hospital and spend 72 hours there then, under Level 2 and 3, you would be eligible for:

  • R10,000 for the 1st day
  • R6,500 for the second day
  • R5,000 for the 3rd day
  • totalling R21,500 for the 3 days spent in hospital
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Pre-Authorisation Explained

In general, all Hospital claims for planned procedures need to be pre-authorised at least 48 hours before you can use the benefit. This is a simple procedure where we determine whether the procedure you need is covered under your benefits and whether you still have available amounts left over after previous claims.

To preauthorise a hospital procedure, call Africa Assist on 0861 911 011 and identify yourself as an EssentialMED member with your Policy Number. They will guide you further on what information they need.

You can find more detail about the process on the Claims page.

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What are the Waiting Periods?

There is a 3 month waiting period for any admission day cover.

Stated conditions, on Level 3, have additional waiting periods:

  • 12 month waiting period for stated conditions
  • 24 month waiting period for hysterectomy
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How are the Stated Conditions covered?

Benefit Level 3 includes cover for the treatment of specific stated conditions. These are listed as

  • R20,000 for hernia
  • R35,000 for appendectomy
  • R35,000 for gallbladder/kidney stone
  • R10,000 for miscarriage
  • R45,000 for hysterectomy

These stated conditions have specific limits of cover and are paid out regardless of the number of days spent in hospital. This is different to other illnesses which are paid out as per the admission days up to 21 days.

For example, if you are admitted for kidney stone treatment and only spend 24 hours in hospital, then the R35,000 is available for treatment and not just the R10,000 for the 1st day in hospital.

Stated conditions have different waiting periods:

  • 12 month waiting period for stated conditions
  • 24 month waiting period for hysterectomy
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How can I increase my cover?

The Hospital Plan includes additional benefits that can be added when you choose to take out the Illness Hospitalisation benefit. These optional benefits can increase your cover for more specific events. Take a look at:

  • ICU benefit for additional cover for stays in an intensive care unit
  • Dread Disease cover which offers larger amounts to help cover treatment of specific critical illnesses
  • Maternity cover which has a stated amount to cover the birth of your child in hospital.
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How does this relate to the Accident Hospitalisation benefit?

The Accident Hospitalisation benefit is designed to offer generous cover for the treatment of all medical costs related to an accident event.

The Illness Hospitalisation benefit is designed to offer cover for hospital costs that are not related to an accident.

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Claims paid directly to providers
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Answers to Your Questions

Is there a waiting period for the Illness Hospital benefit?

The benefit has a 3 month waiting period. Condition specific waiting periods and exclusions may apply for any pre-existing medical conditions.

Where I can find the network hospitals?

The benefit doesn't have a specific hospital network and is designed to work with all major hospital groups. The Network page has all the information needed.

How are claims paid?

Claims are paid directly to the medical providers. You can find all the details on our claims page.

What are the age limits?

All new members joining a policy must be younger than 65 years on date of application.

Child dependants must be younger than 21 years before they will need to start their own policy.

However, if your child is still a registered full-time student and unmarried, then they may stay on the policy as a child dependant until they turn 26.

How many people can be on a policy?

Episodic health insurance policies can include:

  • you
  • your spouse/partner
  • up to 6 children