Rules as registered by the Registrar – Version 4.2010
1.
RULES OF MEDIHELP
(As registered in English)
1. Name of the Medical Scheme
The name of the medical scheme is “Medihelp”.
2. Legal Persona
Medihelp may, in its own name, sue and be sued, purchase or otherwise acquire, hold, mortgage, let and alienate property, movable and immovable and do or cause to be done all such things as may be necessary for or incidental to the exercise of its powers or the performance of its function in terms of
the Medical Schemes Act, 1998 (Act No 131 of 1998), the Regulations issued in terms thereof and
these Rules.
3. Registered Office
The registered office of Medihelp is Medihelp Building, 84 Beatrix Street, Arcadia, Pretoria, 0083, but the Board of Trustees has the authority to transfer such office to any other site within the Republic of South Africa if circumstances so dictate.
4. Objectives
The objectives of Medihelp are to undertake liability in return for a subscription to –
4.1 establish and maintain a fund from subscriptions payable by members and other
contributions received from any other source, to, subject to the conditions and basis as
contained in the Rules, grant financial assistance to members and/or their registered
dependants in respect of the obtaining of an applicable healthcare service, as stated in
Schedule B; and
4.2 render an applicable healthcare service as stated in Schedule B or any other related
service to members and/or their registered dependants, either by Medihelp itself or by
any supplier of a service or group of suppliers of a service in association with or in terms
of an agreement with Medihelp.
5. Definitions
In these Rules, words defined in the Medical Schemes Act, 1998 (Act No 131 of 1998) have the
same meaning as those assigned to them in the said Act and, unless inconsistent with the context, all
words and expressions denoting the masculine gender shall include the feminine, words denoting the
singular number shall include the plural and vice versa, and the following expressions shall have the
meaning hereby assigned to them –
“Act” means the Medical Schemes Act, 1998 (Act No 131 of 1998) and any regulations
issued in terms of the provisions of the said Act.
“All-inclusive nursing service” means a service rendered by a professional, registered
person as alternative to hospitalisation, as authorised beforehand by the Principal Officer
at the hand of managed healthcare programmes.
“Annexure” means an annexure to the Rules that is considered part of the Rules.
“Applicant” means a person who applies for membership for himself and registration of
his dependants, if any.
“Application” means an application, in a manner approved by the Board of Trustees, for
membership or for the registration of a dependant.
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“Auditor” means an auditor who is registered in terms of the Public Accountants’ and
Auditors’ Act, 1991 (Act No 80 of 1991).
“Bed day” means, with regard to admission in a hospital, unattached operating theatre
unit, clinic of a local authority or registered step-down facility, each day or portion thereof
that a person is admitted to the facility.
“Beneficiary” means a member or a person registered as a dependant of a member.
“Benefits” means the benefits of Medihelp as stipulated in rule 14 and Schedule B.
“Board of Trustees” means the Board of Trustees as contemplated in section 29(1)(a)
of the Act read with rule 17.
“Broker” means a person whose business, or part thereof, entails providing a service or
advice in respect of the introduction of prospective members to Medihelp, and who has
been accredited as a broker by the Council for Medical Schemes and who has been
contracted with Medihelp for rendering such services.
“Calendar month” means a period extending from the first day to the last day of any
one of the twelve (12) months of the year.
“Chronic medication management programme” means a pre-authorisation
programme, in terms of which prescribed medicine is authorised according to clinical
protocols and formularies in order to register members on the management programme
for the medical treatment of chronic diseases.
“Claim” means a benefit amount to which a member is entitled according to the Rules in
respect of expenditure incurred by him or his dependants in connection with a relevant
health service.
“Condition-specific waiting period” means a period during which a beneficiary is not
entitled to claim benefits in respect of a condition for which medical advice, diagnosis,
care or treatment was recommended or received within the 12-month period ending on
the date on which an application for membership was made.
“Credit facility” means, with regard to the personal medical savings account of a
member of a benefit option, a credit amount available to the member for the payment of
day-to-day expenses.
“Date of application” means the date on which an application for membership and/or
an application for the registration of a dependant is received at the offices of Medihelp.
“Date of service” means –
(a) in the case of a consultation, visit or treatment by a medical practitioner, a
dentist or person providing supplementary health services, the date on which
each consultation, visit or treatment took place, whether it was for the same
illness or not;
(b) in the case of an operation, procedure or confinement the date on which the
operation, procedure or confinement took place;
(c) in the case of hospitalisation, the date of each discharge from hospital, nursing
or maternity home or the date of termination of membership, whichever occurs
first;
(d) in the case of any other service or medical appliance, the date on which the
service was rendered or the medical appliance received; and
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(e) in the case of an accident or event referred to in rule 15.4, the date of final
settlement and/or court order.
“Dependant of a member” means the spouse or partner as well as the dependent
children, father, mother, brothers, sisters and grandchildren of the member and such
other person as acknowledged as a dependant in the exclusive discretion of the Board of
Trustees in respect of whom the member is liable for family care and support, and who is
not a member or a dependant of a member of another medical scheme. For the purpose
of applying this definition, the following shall mean:
(a) “Dependent child” means a child who is not self-supporting and in respect of
whom the member is liable for family care and support. For the purpose of
applying this definition, child means –
(a)(i) the natural child of a member; or
(a)(ii) a stepchild; or
(a)(iii) an adopted child or a child in the process of being adopted and who has been
placed in the custody of the member, as defined in section 1 of the Child Care
Act, 1983 (Act No 74 of 1983); or
(a)(iv) a foster child or a child in the process of being placed in foster care and who
has been placed in the custody of the member, as defined in the Child Care
Act, 1983 (Act No 74 of 1983); or
(a)(v) a child, as defined in (i) to (iv) above, of a member’s partner.
(b) “Family care and support”, means, with regard to the dependant of a
member, the financial care by a member of a dependant who is not selfsupporting.
(c) “Partner” means a person of the same or opposite gender within a relationship
of a dedicated and permanent nature with the member that is comparable to a
marriage based on objective criteria of mutual dependence, and who shares a
common household with the member.
(d) “Spouse” means a person of the opposite gender within a marriage
solemnised in accordance with any Act or custom.
“Designated service provider” means a healthcare provider or group of providers
appointed by Medihelp as preferred provider(s) to provide services to the members in
relation to one or more prescribed minimum benefit condition(s), which may include the
diagnosis and/or treatment and/or care as required by the Regulations issued in terms of
the Act.
“Discretionary medicine” means medicine administered in the consulting rooms for a
specific diagnosis, which medicine must be pre-authorised by the Principal Officer.
“Emergency medical condition” means any sudden and unexpected onset of a health
condition that requires immediate medical or surgical treatment, where failure to provide
such treatment would result in serious impairment to bodily functions or serious
dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy:
provided that the condition is certified as such by a medical practitioner.
“Family” means the member and all his registered dependants.
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“General care” means a service, irrespective of the point of such service, which is
excluded from benefits and which can be rendered by a registered professional person
or any other person in respect of a beneficiary, and which includes assistance with
personal hygiene (bathing, dressing, changing incontinence diapers and similar
assistance), catheter care, oral or tube feeding (excluding the placement of catheters
and tubes), administering and/or supervision of oral, rectal, vaginal or topical medicine,
assistance with mobilisation and comfort care to prevent bedsores.
“General waiting period” means a period in which a beneficiary is not entitled to claim
any benefits.
“Late joiner” means a person, excluding a dependent child, who is thirty five (35) years
of age or older and who applies for membership as a beneficiary, and –
(a) who was not at any time registered as a beneficiary with one or more medical
scheme(s) prior to 1 April 2001; or
(b) was registered as a beneficiary with one or more medical scheme(s) prior to
1 April 2001, but with a continuous interruption in coverage of more than three
(3) months since 1 April 2001.
“Length of stay parameters” means the agreed upon length of stay in a contracted
hospital/facility.
“Life-threatening acute infections” means all life-threatening infections requiring
hospitalisation. Medihelp reserves the right to require proof of the severity of the infection
in whatever form.
“Managed healthcare programmes” means clinical and financial risk assessment and
management of healthcare, to facilitate appropriateness and cost-effectiveness of
relevant health services within the constraints of what is affordable. This is accomplished
by means of a set of formal techniques, as approved by the Board of Trustees, that are
designed to monitor the use of, and evaluate the clinical necessity, appropriateness,
efficacy, and efficiency of healthcare services, procedures and the appropriateness of
the point of service, on the basis of which appropriate managed healthcare interventions
are made.
“Medicine” means a substance or mixture of substances used or purporting to be
suitable for use or manufactured or sold for use in –
(a) the diagnosis, treatment, mitigation, modification or prevention of disease,
abnormal physical or mental state or the symptoms thereof; or
(b) restoring, correcting or modifying any somatic or psychic function.
“Medihelp” means the medical scheme as a legal persona which comprises the
members, the Board of Trustees and the Principal Officer and his staff, as it is indicated
in the Rules respectively.
“Member” means someone who is registered or admitted as a member of Medihelp or
who is a member in terms of the Rules.
“Month” means a period extending from a day in one month to the day preceding the
day corresponding numerically to that day in the following month.
“Monthly income” means the member’s gross monthly remuneration before any
deductions.
“Participating employer” means an employer who has contracted with Medihelp for the
purposes of admission of its employees as members of Medihelp.
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“Personal medical savings account” means an account which is kept by Medihelp on
behalf of a member of a benefit option, which is credited monthly with the member’s
contribution as set out in Schedule A, and which is used to pay medical expenses as set
out in Schedule B.
“Pre-existing medical condition” means a condition for which medical advice,
diagnosis, care or treatment was recommended or received within the 12-month-period
preceding the date on which application for membership is made.
“Prescribed minimum benefit condition” means a condition contemplated in
Annexure A of the Regulations and any emergency medical condition.
“Prescribed minimum benefits” means the benefits contemplated in section 29(1)(o)
of the Act and consist of the provision of the diagnosis, treatment and care costs of –
(a) the diagnosis and treatment pairs listed in Annexure A of the Regulations,
subject to any limitations specified therein; and
(b) any emergency medical condition,
provided that benefits will be allocated from the effective date of the preauthorisation/
pre-registration.
“Principal Officer” means the principal officer appointed in terms of section 57(4)(a) of
the Act.
“Procedure” means any act or action, either surgical or non-surgical in nature,
performed by a service provider(s) in the diagnosis and treatment of a medical condition,
and includes all direct and indirect services relating to the particular service(s), including
hospitalisation, irrespective of where the act or action is performed.
“Protocol” means a set of clinical guidelines in relation to the optimal sequence of
diagnostic testing and treatments for specific conditions and includes, but is not limited
to, clinical practice guidelines, standard treatment guidelines, disease management
guidelines, treatment algorithms and clinical pathways.
“Registrar” means the Registrar or Deputy Registrar(s) of Medical Schemes appointed
in terms of section 18 of the Act.
“Rules” means the Rules of Medihelp as well as –
(a) the provisions of the Act, charter, deed of settlement, memorandum of
association or other document by which Medihelp is constituted;
(b) the articles of association or other rules for the conduct of the business of
Medihelp; and
(c) the provisions relating to the benefits which may be granted by and the
contributions which may become payable to Medihelp.
“Schedule” means a schedule to these Rules which shall be regarded as part of these
Rules.
“Service” means a relevant health service as defined in the Act.
“Southern Africa” means the Republic of South Africa, Botswana, Lesotho, Malawi,
Mozambique, Namibia, Swaziland and Zimbabwe.
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“Subscription” means the amount which in terms of rule 13 is applicable to a particular
member and payable monthly to Medihelp.
“Supplier of service” means a practitioner, person, organisation or an institution which
is authorised in terms of an act to render a relevant health service as defined in the Act.
“Tariff” means the amount on which the benefits of Medihelp shall be calculated, and
the following terms shall have the meanings as shown:
(a) “Cost” is the net amount payable in respect of a relevant health service;
(b) “Guideline tariff” is the tariff for services which is calculated using the
National Health Reference Price List for 2009 as basis plus 8%, and in the case
of medical, surgical and orthopaedic appliances and material for which a
NAPPI (National Pharmaceutical Product Interface) code has been allocated by
the NAPPI Advisory Board (NAB), the applicable price linked to the NAPPI
code;
(c) “Medicine price” is the single exit price plus the applicable professional fee,
where applicable, as published from time to time in terms of the Medicines and
Related Substances Control Act, 1965 (Act No 101 of 1965) as amended;
(d) “Medihelp Dental Tariff” means the benefits for dentistry in accordance with
the dental schedule of the Scheme as agreed between Medihelp and its
contracted dental managed healthcare organisation;
(e) “Medihelp Optometry Tariff” means the benefits for optometry in accordance
with the optometry schedule of the Scheme as agreed between Medihelp and
its contracted optometry managed healthcare organisation;
(f) “Medihelp Reference Price” is the maximum amount on which benefits for
medicine prescribed for the treatment of a chronic sickness condition which is
registered with Medihelp as a prescribed minimum benefit condition are
calculated;
(g) “MMAP” (Maximum Medical Aid Price) is the maximum amount on which
benefits for chronic and non-chronic medicine are calculated, excluding
medicine prescribed for the treatment of a prescribed minimum benefit
condition which is registered as such with Medihelp;
(h) “Scheme tariff” is the tariff as approved by the Board of Trustees and is
contractually agreed with a service provider or a group of service providers,
which includes, but is not limited to, per diem, fixed and global fees; and
(i) “UPFS” (Uniform Patient Fee Schedule) is the tariff issued by the Department
of Health, which is applicable to public hospitals.
“To-take-out medicine (TTO)” means medicine to take out at the time of discharge from
a hospital or day clinic, which medicine directly pertains to the reason for the admission
to the hospital or day clinic and which is dispensed and charged by the hospital or day
clinic on prescription of the attending physician.
6. Membership
Admission
6.1 Any person or group of persons may be admitted as members in terms of the Rules of
Medihelp.
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Application for membership
6.2 An applicant must apply for membership by means of an application form as required by
Medihelp and must provide such additional information as Medihelp may require and is
personally responsible for any expenditure incurred in this regard, except in the case of
medical reports requested by Medihelp.
6.3 A minor as contemplated in section 30(1)(f) of the Act may apply for membership of
Medihelp with the assistance of his parent or guardian.
Date of enrolment as a member
6.4 The applicant will be enrolled as a member from the date requested on the application,
provided that the application is received by Medihelp before the date on which
membership is requested, otherwise enrolment will commence from the date on which
the application is received.
6.5 In the case where Medihelp has an agreement with the applicant’s employer, the
applicant will be enrolled as a member from the date as agreed on with the employer.
Conditions for enrolment as a member
6.6 No person is enrolled as a member of Medihelp while such person is a member of
another medical scheme.
6.7 An applicant will be enrolled as a member subject to a waiting period as contemplated in
rule 8 and/or late-joiner penalty as may be applicable to an applicant and/or his
dependants in terms of the Rules.
Continued membership
6.8 A member may retain his membership together with his dependants in the event of his
retiring from the service of his employer or his employment being terminated by his
employer on account of age, ill health or other disability: provided that he shall be
personally responsible to pay the applicable subscription per debit order to Medihelp.
7. Registration, Deregistration and Continued Membership of Dependants
Application for the registration of dependants
7.1 A member may register all his dependants with Medihelp who qualify in terms of the
Rules, subject to such waiting periods and/or late-joiner penalties as may apply for the
dependant in terms of the Rules.
7.2 A person may not be registered as a dependant of more than one member of Medihelp
or as a dependant of a member of Medihelp and a member of another medical scheme
simultaneously.
7.3 A dependant as contemplated in the definitions may not be enrolled as a dependant of a
member in another benefit option than the benefit option of the member.
7.4 Application must be made on an application form required by Medihelp and Medihelp
may require that any application for the registration of a dependant must be
accompanied by the relevant marriage or birth certificate, adoption order, foster care
order or any other applicable certificate or document which Medihelp may require.
Date of registration of dependants
7.5 A dependant shall be registered –
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7.5.1 from the date on which the application is received or a later date as requested on the
application; or
7.5.2 in the case of a marriage, birth, adoption or where a child is placed in the member’s
foster care, from the date of such occurrence: provided that the application for
registration must be submitted to Medihelp not later than ninety (90) days after the above
date(s): further provided that should the member fail to comply with this stipulation, the
dependant will be registered from the date on which the application is received, subject
to rule 8.5 and such waiting period and/or late-joiner penalties as determined by the
Rules.
Deregistration of dependants
7.6 Medihelp must be advised within one (1) month from the date on which a dependant no
longer qualifies to be registered: provided that –
7.6.1 should the member fail to comply with this notice period, such deregistration may be
implemented at the earliest from the beginning of the calendar month in which the
notification is received; and
7.6.2 in the case of employer groups, deregistration will be implemented from the date as
advised by the employer.
Continued membership of dependants
7.7 The registered dependant of a deceased member shall be entitled to continuous
membership without the imposition of new waiting periods and/or late-joiner penalties,
until such dependant becomes a member or a dependant of a member of another
medical scheme, and is personally responsible to pay the applicable subscription per
debit order to Medihelp: provided that the dependant accepts membership not later than
ninety (90) days from the date on which Medihelp informed such dependant that he
qualifies for continued membership.
8. Application of Waiting Periods
8.1 If a person was not a beneficiary of a medical scheme for a period of ninety (90) days or
more preceding the date of enrolment at Medihelp the following waiting periods may be
imposed, which waiting periods shall also apply to the prescribed minimum benefits:
8.1.1 A general waiting period of up to three (3) months.
8.1.2 A condition-specific waiting period of up to twelve (12) months.
8.2 If a person was a beneficiary of a previous medical scheme or schemes for a continuous
period of up to twenty-four (24) months, terminating less than ninety (90) days
immediately prior to the date of enrolment at Medihelp, the following waiting periods may
be imposed:
8.2.1 A condition-specific waiting period of up to twelve (12) months, except in respect of a
prescribed minimum benefit condition.
8.2.2 Where the previous medical scheme had imposed a general or condition-specific waiting
period, and such waiting period had not expired at the time of termination of
membership, the unexpired duration of such waiting period may be imposed by
Medihelp.
8.3 Medihelp may impose a general waiting period of up to three (3) months, except in
respect of a prescribed minimum benefit condition, upon any person who was previously
a beneficiary of a medical scheme or schemes for a continuous period of more than
twenty-four (24) months, terminating less than ninety (90) days immediately prior to the
date of enrolment at Medihelp.
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8.4 No waiting period shall be imposed upon a beneficiary who changes from one benefit
option to another: provided that any remaining period of existing waiting periods may be
applied.
8.5 A waiting period shall not be imposed on the child of a member born during the period of
membership.
8.6 In the following cases Medihelp shall not impose a general or condition-specific waiting
period upon a person in respect of whom an application is made for membership or
admission as a dependant if such person was previously a beneficiary of a medical
scheme, terminating less than ninety (90) days immediately prior to the date of enrolment
at Medihelp: provided that Medihelp may apply any remaining period of existing general
and condition-specific waiting periods applied by the previous medical scheme:
8.6.1 where the termination of membership of the previous scheme is required as a result of
change of employment; and
8.6.2 where an employer changes or terminates the medical scheme of its employees and
enrols them at Medihelp, provided that such termination shall occur at the beginning of
Medihelp’s financial year, or that notice is received from the employer on or before
30 September of the preceding financial year that such transfer shall occur at the
beginning of the next financial year.
8.7 Should the lapse in membership referred to in rule 8.6 be ninety (90) days or longer, a
general waiting period of up to three (3) months and a condition-specific waiting period of
up to twelve (12) months may be imposed.
8.8 If the members of a medical scheme who are members of that medical scheme by virtue
of their employment by a particular employer terminate their membership of the said
medical scheme with the object of obtaining membership of Medihelp, Medihelp shall
admit to membership, without a waiting period or the imposition of new restrictions on
account of the state of those members’ health or the health of any of their dependants,
any member or a dependant of such a medical scheme who –
8.8.1 enjoy continued membership of such a scheme; or
8.8.2 enjoy continued membership of such a scheme as the dependant of a deceased member
of such a scheme.
9. General Stipulations Applicable to Waiting Periods
Requesting medical reports
9.1 Medihelp may require that a medical report be provided in respect of any pre-existing
medical condition before a beneficiary is enrolled, and the cost of such medical report
shall be paid for by Medihelp: provided that –
9.1.1 Medihelp may designate a service provider to provide such medical report; and
9.1.2 should the applicant make use of a service provider other than the service provider
designated by Medihelp, the applicant shall be responsible for payment of the cost of
such examination.
9.2 In cases where Medihelp is responsible for payment of an account, the applicant must
submit a specified account to Medihelp.
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10. General Stipulations with regard to Membership
Proof of membership
10.1 Proof of membership, on which shall be indicated such details as prescribed by the Act,
shall be issued to every member on enrolment and with each change in membership
details.
Membership card
10.2 A membership card shall be issued to every member on enrolment and with each
change in beneficiary details and/or change in benefit option. This card, which remains
the property of Medihelp, must be produced on request to a supplier of service and must
be returned to Medihelp on termination of membership.
10.3 The utilisation of a membership card by any person other than the member and/or his
registered dependants, with the knowledge or consent of the member and/or his
registered dependants is not permitted and shall be construed as a fraudulent act.
Certificate of membership
10.4 Medihelp shall, on the termination of membership, deregistration of a dependant or on
request of a member, furnish a certificate of membership to such person within one (1)
month from the date of the termination of membership or the request.
Change of address
10.5 Medihelp must be advised within one (1) month of any change of address: provided that
such address shall be within the borders of the RSA. Medihelp shall accept no liability or
responsibility in the event of a member being prejudiced on account of his failure to
comply with this rule.
Applicability of the Rules
10.6 A detailed summary of the Rules containing the member’s rights and responsibilities
shall be sent free of charge to a member on enrolment.
10.7 The Rules shall be binding on every beneficiary and approval by Medihelp of the
member’s application for membership and/or registration of a dependant shall be
regarded as the unqualified undertaking of the beneficiaries to abide by the Rules and
any amendment thereto.
Banking details
10.8 A member must furnish Medihelp with the relevant banking details at such recognised
financial institution in the RSA for the recovery of subscription and with any changes to
such details, and Medihelp shall accept no responsibility/liability for any debit order
recovery made in error due to erroneous information furnished to Medihelp or outdated
information in the possession of Medihelp.
11. Termination of Membership
11.1 A member whose membership has been terminated shall, from the date of such
termination, have no further claims against Medihelp or the assets of Medihelp except in
respect of accounts for services rendered before the date on which the termination of
membership became effective and provided that a claim was submitted in accordance
with rule 15.
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Resignation of a member who is an employee of a participating employer
11.2 No person for whom membership of Medihelp is a condition of service in terms of an
agreement between Medihelp and an employer may, while he remains in service, resign
without the consent of his employer or be deprived of his membership by Medihelp
without prior notification to his employer.
11.3 An employer’s participation in Medihelp shall be terminated in accordance with the notice
period as determined in the agreement between Medihelp and the employer.
Voluntary termination by a member who is not part of a participating employer
11.4 Voluntary termination of membership by a member must be done in advance in writing
and such date of termination shall not be a date prior to the date on which Medihelp
received the request, while any claim to benefits shall terminate after the last day of
membership.
Death of the member
11.5 The membership of a deceased member shall terminate on the day following the date of
death.
Failure to pay amounts due to Medihelp
11.6 If a member fails to pay subscription and/or any other amount due to Medihelp on the
date on which it became due, Medihelp shall notify such member and participating
employer thereof and inform the member and/or participating employer that if it is not
settled on the date indicated in the letter, benefits shall be suspended in respect of
claims which arose during the period of default and that membership may be terminated
if the arrears subscription and/or amount due is not remitted within thirty (30) days from
the date of suspension: provided that the Principal Officer may, in his exclusive
discretion, determine the period in which the arrears subscription and/or other amount
due may be remitted and interest may be charged at the prime rate of Medihelp’s
bankers.
Abuse of rights, falsified claims, misrepresentation and non-disclosure of material information
11.7 Medihelp may suspend the benefits of a beneficiary and/or terminate his membership if
he –
11.7.1 submitted a fraudulent claim;
11.7.2 committed a fraudulent act; or
11.7.3 failed to disclose material information on the request of Medihelp.
11.8 Should it be determined, after a member has been accepted, that he has in any
application supplied false information or withheld material information, the membership of
such a member may in the discretion of Medihelp, subject to the provisions of rule 11.2,
be terminated and any amount paid as benefits by Medihelp shall be refunded.
12. Special Categories of Members
Certain civil pensioners
12.1 Medihelp renders a medical scheme service on behalf of the State for –
12.1.1 certain civil pensioners who are exempt from the payment of subscription; and
12.1.2 members who obtained membership of Medihelp at the time of the dissolving of the
former Development Boards.
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13. Subscription
13.1 The member shall be responsible for payment of the full applicable subscription, and
irrespective of whether any waiting period is imposed on a beneficiary, the prescribed
subscription, as indicated in Schedule A, shall be due on the first day of enrolment and
thereafter on the first day of each subsequent calendar month, although it shall be
payable retroactively at the end of each calendar month in which a person is enrolled as
a beneficiary, and shall be paid not later than the first working day following the end of
each calendar month: provided that –
13.1.1 the subscription may be paid partially or in full by the member’s employer or former
employer to Medihelp, in which case it is done in his capacity as the authorised agent of
the member; and
13.1.2 a member who is personally responsible to pay the subscription in full or partially, must
pay it by means of a debit order, in which case the member’s banker shall act as his
authorised agent in the payment thereof: provided that Medihelp may, in its sole
discretion, after receiving an application from the member, approve that the subscription
may be paid by a means other than by debit order; and
13.1.3 in those cases where subscription is paid by the member’s employer/previous employer
it must be paid not later than the last working day following the month in which it
becomes payable.
13.2 At a change in dependants, subscription shall –
13.2.1 increase from the first day of the calendar month in which a person is registered as a
dependant, excluding newborns registered from the date of birth, in which case
subscription shall increase from the beginning of the calendar month following the month
of registration; and
13.2.2 decrease from the first day of the calendar month following the calendar month in which
a person’s registration as a dependant is cancelled.
13.3 The subscription of a dependent child shall increase to that of a dependant other than a
dependent child, from the beginning of the calendar month in which the dependent child
reaches the age as applicable for the particular benefit option contained in Schedule A to
the Rules.
13.4 No refund of any assets of Medihelp or any portion of a contribution, excluding the
contributions by a member to a personal medical savings account, shall be paid to any
person where such member’s membership or registration of any dependant terminates
during the course of a month.
13.5 The balance standing to the credit of a member in terms of a personal medical savings
account shall at all times remain the property of the member.
13.6 In the case of uninterrupted continued membership of dependants after the death of a
principal member, the subscription of such re-registered dependants shall only be
payable from the beginning of the calendar month following the calendar month of the
principal member’s death.
14. Benefits
14.1 On enrolment, an applicant has to choose to participate in one of the benefit options as
contemplated in Schedule B and he together with his dependants shall be entitled to the
benefits offered by that benefit option during a financial year.
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14.2 Medihelp, or its contracted managed healthcare organisation, shall pay any benefit due
to a member on the grounds of a valid claim, either to the member or to the supplier of
service, within thirty (30) days after receipt of the claim.
14.3 Subject to the provisions of rule 8.1, benefit options shall offer 100% cover of the cost of
the prescribed minimum benefits, without any member levies, member contributions or
limits, provided that the conditions contemplated in Schedule B and Annexure 2 are met.
14.4 In relation to a service rendered outside Southern Africa –
14.4.1 benefits shall only be granted on medical services rendered during the first ninety (90)
days as from the date of departure to treat an emergency medical condition: provided
that a beneficiary who is working or studying outside Southern Africa on instruction of his
employer shall not be subject to this limitation;
14.4.2 benefits shall be calculated according to the applicable tariff of a similar service rendered
in the Republic of South Africa; and
14.4.3 the claim must be submitted with the documentation as may be required by Medihelp or
its contracted managed healthcare organisation.
14.5 Medihelp or its contracted managed healthcare organisation may, on such conditions as
it may determine, make such contribution as would be the normal contribution of
Medihelp in respect of a claim arising from an accident or events for which a member or
a dependant has received or is likely to receive compensation from any source
whatsoever, including travel insurance: provided that the member must cede any claim
for medical expenses against a third party to Medihelp or its contracted managed
healthcare organisation.
14.6 Except in the case of an emergency medical condition –
14.6.1 Medihelp or its contracted managed healthcare organisation may require preauthorisation/
registration before a relevant health service is rendered: provided that
benefits may be forfeited or a member contribution contemplated in Schedule B and
Annexure 2 may be required should a member fail to obtain preauthorisation/
registration;
14.6.2 Medihelp may limit a beneficiary to make use of the services of only one selected
contracted supplier of services per discipline should the beneficiary qualify for
participation in a managed healthcare programme;
14.6.3 Medihelp may prohibit a beneficiary qualifying for participation in a managed healthcare
programme from submitting claims to the Scheme should a contractual agreement for
the direct submission and payment of scheme benefits exist between the Scheme and
the contracted supplier; and
14.6.4 Medihelp may in cases where a clinical opinion has been obtained by the Scheme that
the beneficiary does not utilise a medicine item(s) appropriately, decline authorisation for
such item(s) and not bear the financial responsibility with regard to such medicine items
obtained from the non-chronic medicine benefit, or hospitalisation/treatment necessitated
as a result of the inappropriate utilisation of such medicine.
14.7 The benefit exclusions in Schedule C shall be applicable to all benefit options, except in
the case of prescribed minimum benefits.
14.8 A beneficiary must apply to be registered on the chronic medication management
programme and an application shall only be considered if –
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14.8.1 the illness is of a chronic nature;
14.8.2 the illness will continue indefinitely in its present state;
14.8.3 regular and continuous medicinal treatment is required; and
14.8.4 the medicine which is prescribed is considered by Medihelp to be life-saving and lifesustaining.
14.9 A person who is not a beneficiary of Medihelp may not claim or receive benefits from
Medihelp or its contracted managed healthcare organisation.
14.10 The allocation of benefits shall be subject to the applicable managed healthcare
programmes as approved by the Board of Trustees, where applicable, which includes
obtaining a second opinion by a relevant specialist on request of Medihelp.
Prohibition on cession and attachment of benefits
14.11 No benefit or right in respect of a benefit payable under these Rules may be assigned or
transferred or otherwise ceded or be pledged or hypothecated or be attached or
subjected to any form of execution under a judgement or order of a court of law.
14.12 Medihelp or its contracted managed healthcare organisation may withhold, suspend or
discontinue the payment of a benefit to which a member is entitled under these Rules or
any right in respect of such benefit or payment of such benefit to such a member, if a
member attempts to assign or transfer or otherwise cede or to pledge or hypothecate
such benefit.
15. Claim Procedures
Valid claim
15.1 A claim must be submitted to Medihelp or its contracted managed healthcare
organisation within the prescribed period according to contractual stipulations in the case
of suppliers of service, and an account must be specified as follows in order to be
considered as a valid claim:
15.1.1 The surname and initials of the member.
15.1.2 The surname, first name, other initials (if any) and date of birth of the patient as indicated
on the proof of membership.
15.1.3 The name of the scheme.
15.1.4 The membership number of the member.
15.1.5 The practice code number, group practice code number, and individual provider
registration number issued by the relevant registering authorities for suppliers of
services, if applicable, and in the case of a group practice, the name and practice code
number of the practitioner who rendered the services.
15.1.6 The date on which each service was rendered.
15.1.7 The nature and cost of each relevant health service and where such a supplier of service
supplied medicine direct to such beneficiary, the name, quantity and dosage as well as
the net amount payable by the member in respect of such medicine.
15.1.8 The relevant 5-character diagnostic ICD-10 code and such other item code numbers,
including CPT4, where applicable.
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15.1.9 Where a pharmacist supplies medicine on prescription to a beneficiary, Medihelp may
request a copy of the original prescription or a certified copy of such prescription.
15.1.10 The name and practice code number of the referring/prescribing medical practitioner or
dentist.
15.1.11 In the case where an account or statement refers to the use of an operating theatre
(where an operation was performed on the beneficiary) –
15.1.11.1 the name, practice code number and registration number contemplated in rule 15.1.5 of
the medical practitioner or dentist who performed the operation,
15.1.11.2 the name or names, practice code numbers and registration numbers contemplated in
rule 15.1.5 of every medical practitioner or dentist who assisted at such operation, and
15.1.11.3 the reference number provided by Medihelp or its contracted managed healthcare
organisation in the case of services that require pre-registration or pre-authorisation.
15.1.12 An account or statement in respect of orthodontic treatment or other advanced dentistry,
a treatment plan indicating –
15.1.12.1 the expected total amount that will be charged for the treatment;
15.1.12.2 the expected duration of the treatment;
15.1.12.3 the initial amount payable by the member; and
15.1.12.4 the monthly amount payable.
15.2 Where a member has paid an account, Medihelp or its contracted managed healthcare
organisation may require that the receipt issued by the supplier of service accompany
the claim.
15.3 In the case of claims for services rendered abroad, an explanation/exposition of the
service as well as the name of the country in which the services were rendered must be
supplied.
15.4 A claim arising from an accident or event in respect of which a beneficiary has received
or is likely to receive compensation from any source whatsoever must be accompanied
by an exposition of the conditions under which such injury or accident has arisen.
Prescribed period for the submission of claims
15.5 In order to qualify for benefits a claim must be submitted to Medihelp, its collector or its
contracted managed healthcare organisation not later than the last day of the fourth
calendar month following the month in which the service was rendered: provided that
Medihelp or its contracted managed healthcare organisation may extend the period in
the case of a service rendered abroad.
15.6 If Medihelp or its contracted managed healthcare organisation is of the opinion that a
claim is incorrect, incomplete or unacceptable for payment, Medihelp or its contracted
managed healthcare organisation shall inform the member and supplier of service within
thirty (30) days after receipt of such claim of the reasons for rejecting such claim and
afford the member and supplier of service an opportunity to submit an improved claim to
Medihelp, its collector or its contracted managed healthcare organisation within sixty (60)
days following the date from which the notice of the rejection was issued.
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15.7 It shall be the duty of a member to obtain accounts from a supplier of service for all
services rendered and to ensure that all claims are submitted and finalised within the
prescribed submission period, irrespective of whether the supplier has undertaken to
submit the account to Medihelp or its contracted managed healthcare organisation.
Should a member be unable to obtain an account for services rendered because of the
extended nature of the treatment or for any other reason whatsoever, or if he has in fact
received an account but, because of circumstances beyond his control, is unable to
submit it within the prescribed submission period, Medihelp or its contracted managed
healthcare organisation may extend the said period at its discretion, on condition that a
written application for extension is received by Medihelp or its contracted managed
healthcare organisation before the expiration of the prescribed submission period.
15.8 Should a member be unable to submit a claim within the prescribed submission period
due to the nature of his indisposition, Medihelp or its contracted managed healthcare
organisation may, at its discretion, and after satisfactory evidence has been given, grant
an extension of the said period.
15.9 Medihelp or its contracted managed healthcare organisation may at its discretion grant
an extension of the prescribed submission period when membership has ceased due to
the death of a member.
Payment of amounts due to members and suppliers of service
15.10 Subject to the provisions of the Act, Medihelp or its contracted managed healthcare
organisation may decide whether Medihelp’s contribution on the claim shall be in the
form of a direct payment to the supplier of service or to the member: provided that the
method used to conclude each claim/corrected claim shall be shown clearly on the
summarised claim statement sent to the member containing at least the following details:
15.10.1 The name and the membership number of the member.
15.10.2 The name of the supplier of service.
15.10.3 The date on which the service was rendered.
15.10.4 The amount charged by the supplier of service for the service.
15.10.5 The benefit amount for such service.
15.11 Payment of a claim shall be limited to the benefit allocation in respect of the relevant
service as provided for in the applicable benefit option.
15.12 Payment of amounts due to a member or service provider shall be made by means of a
transfer to a bank account at such recognised financial institution in the RSA as
furnished to Medihelp by the member/supplier of service, and Medihelp shall accept no
responsibility/liability for a payment made due to erroneous information furnished by the
member/supplier of service or outdated information in the possession of Medihelp.
15.13 Medihelp shall make a refund to a member where a member’s credit amounts to R30.00
or more. On termination of the membership of a member, any amount of R5.00 or more
to his credit, shall be paid to the member.
15.14 In the event that Medihelp or its contracted managed healthcare organisation made a
payment in respect of a claim, a portion of a claim or any benefit to which the
beneficiary/former beneficiary is not entitled, such payment shall be reclaimed by
Medihelp from the member/former member or supplier of service to whom the payment
was made.
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16. Liability of Members and Participating Employers
16.1 The liability of a participating employer to Medihelp shall be limited to the amounts
payable in terms of the agreement between the employer and Medihelp.
16.2 The liability of a member to Medihelp shall be limited to the amount of his subscription
owing as well as any other amount paid by Medihelp on behalf of the beneficiary and that
has not been refunded to Medihelp.
16.3 In the case of a member whose membership has terminated, Medihelp shall be entitled
to recover any amount owing to Medihelp by such member.
Jurisdiction
16.4 A magistrate’s court shall have jurisdiction in any action or process which may be
instituted against a member/participating employer or former member/participating
employer for the recovery of amounts owing to Medihelp and/or any other amount for
which the said member/participating employer or former member/participating employer
is liable or may become liable in future.
16.5 Should Medihelp, by virtue of the member’s failure and/or that of his dependants to
observe the rules and/or pay the amounts contemplated above, be compelled to institute
any legal action, the member shall be responsible to pay Medihelp’s legal costs on an
attorney-client scale and collection commission and recovery costs as prescribed shall
be payable, if applicable.
16.6 No agreement as contemplated in rule 11.6 shall encroach upon Medihelp’s rights or in
any way be prejudicial thereto.
17. Governance
Composition of the Board of Trustees
17.1 The business of Medihelp shall be managed according to the Rules by a Board of
Trustees who is fit and proper to manage the business of Medihelp and is composed as
follows:
17.1.1 Six (6) members of Medihelp elected at the annual general meeting for a period of three
(3) years from a list of nominated candidates.
17.1.2 Subject to section 57(2) of the Act, three (3) trustees of any medical scheme with which
Medihelp has amalgamated, according to an agreement with Medihelp, to serve on the
Board of Trustees for an interim period until the next Annual General Meeting of
Medihelp.
17.1.3 Three (3) members of Medihelp co-opted by the Board of Trustees for a period of three
(3) years, on the grounds of their expert knowledge relating to the business of a medical
scheme: provided that such members shall not have the right to vote.
17.2 The following persons are not eligible to serve on the Board of Trustees:
17.2.1 a director, employee, officer, consultant, or contractor of the administrator of Medihelp, or
of the holding company, subsidiary, joint venture, or associate of the administrator of
Medihelp;
17.2.2 a broker;
17.2.3 the Principal Officer, the employees of Medihelp as contemplated in rule 25, and
individuals who render services as contractors to Medihelp;
17.2.4 the auditor of Medihelp; and
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17.2.5 a person younger than twenty-one (21) years.
Nomination and election of elected members
17.3 Any member of Medihelp may nominate a candidate who is a member of Medihelp,
excluding those persons stated in rule 17.2, for election to the Board of Trustees on a
form as approved by the Board of Trustees.
17.4 Each nomination must be made on the form available from Medihelp, signed by the
candidate, proposer and seconder (the latter two parties may not be the candidate) and
submitted to reach Medihelp before the close of business on the last working day of
March of each year. A nomination shall be invalid if –
17.4.1 it is received after the closing date;
17.4.2 it is not completed in full; or
17.4.3 it is not signed by all three parties mentioned.
17.5 In the event of insufficient nominations having been received by the closing date
mentioned in rule 17.4, the annual general meeting may, in the manner prescribed for
the holding of general meetings, nominate candidates for election to the Board of
Trustees.
17.6 A member of the Board of Trustees whose tenure of office expires shall be eligible for reelection.
17.7 The members at the annual general meeting can from the list of nominated candidates
elect a maximum of six (6) alternate members to the Board of Trustees.
Tenure of Office
17.8 The tenure of office of members of the Board of Trustees commences when they are
declared properly elected, assigned or appointed.
17.9 The tenure of office of a member of the Board of Trustees ends when –
17.9.1 he dies;
17.9.2 he resigns or when his assignment or appointment is revoked;
17.9.3 his membership of Medihelp terminates or is terminated in terms of rule 11;
17.9.4 he is declared insane or incapable of managing his affairs by a court;
17.9.5 his estate has been sequestrated or surrendered or allocated for the benefit of his
creditors;
17.9.6 he is convicted, in the Republic of South Africa or elsewhere, of theft, fraud, forgery or of
uttering a forged document or of perjury;
17.9.7 he is found guilty of any offence and sentenced to imprisonment without the option of a
fine;
17.9.8 he is removed by a competent court of law from any office of trust on account of
misconduct;
17.9.9 he is absent from three (3) consecutive meetings without the consent of the Chairman of
the Board of Trustees;
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17.9.10 a motion of no confidence in a member is accepted by an annual general meeting or a
special general meeting with a two-thirds majority of members who are entitled to vote,
who are either present in person or by proxy: provided that the stipulations of section 46
of the Act must be taken into consideration;
17.9.11 an annual general meeting takes place in the year that his tenure of office of three (3)
years expires;
17.9.12 he is disqualified under any law from carrying on his profession;
17.9.13 he is removed from office by the Council for Medical Schemes in terms of the stipulations
of section 46 of the Act; and
17.9.14 he is removed from office by the Board of Trustees: provided that –
17.9.14.1 before a decision is taken to remove the Board member, the Board shall furnish such
member with full details of the information which the Board has in its possession
regarding the conduct of the member on which a complaint was received, and allow such
member a period of not less than thirty (30) days to respond to the allegations;
17.9.14.2 the resolution to remove such member is taken by at least two thirds of the members of
the Board of Trustees; and
17.9.14.3 the member shall have recourse to the disputes procedures of the Scheme or the
complaints and appeal procedures provided for in the Act.
Filling of vacancies on the Board of Trustees
17.10 The Board of Trustees has the power to fill any vacancy that may occur: provided that
vacancies shall only be filled from the list of nominated candidates laid before the most
recent general meeting in sequence of candidates who recorded the most votes.
17.11 Should the members no longer constitute a quorum, a special general meeting shall be
called to fill such vacancy(ies).
17.12 Members so appointed shall hold office for the unexpired period of office of the retiring
member.
Election of Chairman and Vice-Chairman
17.13 At the first meeting of the Board of Trustees after the annual general meeting, or after a
special general meeting referred to in rule 17.11, the members of the Board of Trustees
with voting rights, shall, from the ranks of members with voting rights, elect a chairman
and a vice-chairman who shall be chairman and vice-chairman respectively of Medihelp
and who shall remain in office until after the following annual general meeting: provided
that, should voting result in a tie, another election shall be held and should voting again
result in a tie, the result will be determined by flipping a coin.
Meetings of the Board of Trustees
17.14 The Board of Trustees shall meet at least once every three months and such meetings
may be held by telephone or electronic conferencing means.
17.15 The chairman, or in his absence the vice-chairman, may call additional meetings in order
to discuss specific matters, which matters shall be stated in the agenda. Any other two (2)
members of the Board of Trustees may request the chairman in writing to call a special
meeting of the Board of Trustees to discuss specific matters, which matters shall be
stated in the agenda.
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17.16 One (1) more than half of the total number of members entitled to vote that have been
appointed or elected to the Board of Trustees, constitute a quorum: provided that a
quorum may not be less than four (4) members.
17.17 Matters serving before the Board of Trustees are determined by a majority of votes and
in the event of a tie of votes, the chairman shall have a casting as well as a deliberative
vote.
17.18 In the event that both the chairman and the vice-chairman are absent from a meeting of
the Board of Trustees, the members of the Board of Trustees shall appoint an acting
chairman from their ranks.
Remuneration
17.19 Members of the Board of Trustees shall be entitled to a honorarium for the execution of
their duties as members of the Board of Trustees: provided that the honorarium shall be
payable in accordance with the policy, as approved by the annual general meeting, for
attending meetings of the Board of Trustees and committees of the Board of Trustees.
Any other costs incurred by a member of the Board of Trustees on instruction of the
Board of Trustees shall be payable in accordance with the policy as determined by
Medihelp.
18. Duties of the Board of Trustees
18.1 The Board of Trustees is responsible for the proper management of Medihelp in terms of
the Rules of Medihelp.
18.2 The Board of Trustees shall act with due care, diligence, skill and in good faith.
18.3 Members of the Board of Trustees shall take all reasonable steps to avoid conflicts of
interest and shall declare any interest they may have in a matter serving before the
Board of Trustees.
18.4 The Board of Trustees shall apply sound business principles and shall see to it that the
financial soundness of Medihelp is maintained.
18.5 The Board of Trustees –
18.5.1 must appoint the Principal Officer, who is fit and proper to hold such office: provided that
a person shall not be the principal officer of Medihelp if that person is a director,
employee, officer, consultant, or contractor of the administrator of Medihelp, or of the
holding company, subsidiary, joint venture, or associate of the administrator of Medihelp,
or a broker;
18.5.2 must remove the Principal Officer from office should any of the conditions stated in rule
17.9.1 to rule 17.9.9 be applicable to him;
18.5.3 can appoint any staff required for the proper execution of the business of Medihelp; and
18.5.4 must determine the conditions of service of the Principal Officer and any other person
employed by Medihelp.
18.6 The chairman of the Board of Trustees must preside over meetings of the Board of
Trustees and shall ensure due and proper conduct at such meetings.
18.7 The Board of Trustees must cause minutes of the proceedings of all annual general
meetings, special general meetings and meetings of the Board of Trustees, to be
recorded and that the minutes of such meetings be submitted to the relevant subsequent
meeting: provided that the minutes of a special general meeting shall be submitted to the
annual general meeting. Should the minutes of any such meetings be accepted and
confirmed as correct, it must be signed by the chairman.
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18.8 The Board of Trustees must ensure that proper control systems are employed by or on
behalf of Medihelp.
18.9 The Board of Trustees must ensure that adequate and appropriate information is
communicated to the members of Medihelp regarding their rights, benefits, contributions
and duties in terms of the Rules of Medihelp.
18.10 The Board of Trustees must take all reasonable steps to ensure that contributions are
paid timeously to Medihelp in accordance with the Act and the Rules.
18.11 The Board of Trustees must take out and maintain an appropriate level of professional
indemnity insurance and fidelity guarantee insurance.
18.12 The Board of Trustees must obtain expert advice on legal, accounting and business
matters as required, or on any other matter of which the members of the Board of
Trustees may lack sufficient expertise.
18.13 The Board of Trustees must ensure that the Rules, operation and administration of
Medihelp comply with the provisions of the Act and all other applicable laws.
18.14 The Board of Trustees must take all reasonable steps to protect the confidentiality of
medical records concerning any beneficiary’s state of health.
18.15 The Board of Trustees must see to it that all disbursements are properly authorised.
18.16 The Board of Trustees must cause to be kept in safe custody, in a safe or strong-room at
the registered office of Medihelp or with any financial institution approved by the Board of
Trustees, any mortgage bond, title deed or other security belonging to or held by
Medihelp, except when in the temporary custody of another person for the purposes of
Medihelp.
18.17 The Board of Trustees must cause to be kept such books of accounts, accounts and
registers that are necessary for the proper functioning of Medihelp.
18.18 The members of the Board of Trustees shall disclose annually in writing to the Registrar
any payment or considerations made to them by Medihelp.
18.19 Details of the remuneration and allowances paid to members of the Board of Trustees,
which must be included in the annual financial statements in terms of regulation 6A of the
Act, must be published in detail in the documentation for the Annual General Meeting
circulated to members, and must indicate the number and nature of the meetings
attended by every member of the Board of Trustees.
19. Powers of the Board of Trustees
The Board of Trustees has the following powers:
19.1 To act in the name of Medihelp and to enter into contracts (including, but not confined to,
contracts concerning the purchase, mortgage, hire, lease and alienation of immovable
property, rendering of services to members and the direct submission of accounts to
Medihelp by suppliers of service, on behalf of members and the direct payment of
accounts to suppliers of service on their behalf) and to transact all such business which
is advantageous for the achievement of the objectives and proper management of
Medihelp.
19.2 To appoint a duly accredited administrator on such terms and conditions as determined
by the Board of Trustees, for the proper execution of the business of Medihelp, which
appointment shall be contained in a written contract, which complies with the
requirements of the Act and the Regulations.
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19.3 To institute and defend any lawsuit which may be necessary for safeguarding the interest
of Medihelp.
19.4 To invest funds to obtain direct or indirect interest in an institution/enterprise which
renders a “service”, and lend, invest, put out on interest, deposit, advance or otherwise
deal with such money as is not immediately required to cover the current expenditure of
Medihelp, upon such security and in such manner as the Board of Trustees may
determine, and to realise such investment, vary, re-invest or otherwise deal therewith as
the Board of Trustees may determine.
19.5 To borrow money on current account from Medihelp’s bankers against the security of the
assets of Medihelp if approved by the Council for Medical Schemes.
19.6 To maintain reserve funds and determine the amounts thereof from time to time.
19.7 To appoint, compensate and determine the level of services of any broker for the
introduction and retention of a member of Medihelp.
19.8 To appoint at its discretion a collector for Medihelp under such conditions as it may
determine.
19.9 To utilise funds for the purpose of promoting the objectives of Medihelp and make
contributions to any association instituted for the benefit of medical schemes.
19.10 To appoint the Principal Officer and other staff in accordance with such conditions as the
Board of Trustees may from time to time determine, and take all necessary steps to sign
and execute all documents required to ensure and secure the due fulfilment of
Medihelp’s obligations under such appointments.
19.11 To suspend or terminate the services of any employee of Medihelp: provided that the
termination of the services of the Principal Officer shall require to be approved by at least
two-thirds of the full Board of Trustees.
19.12 To approve, whenever a member is able to satisfy the Board of Trustees that he, for
reasons acceptable to the Board of Trustees, could not comply with the provisions of a
rule and has consequently been prejudiced thereby, that the benefits such member
would have received had he complied with the rule concerned, be granted to him.
19.13 To decide, at its discretion, on any matter not specifically covered by the Rules: provided
that in the execution of this discretion the Board of Trustees shall be bound by the
objectives of Medihelp, the Rules and the stipulations of the Act.
19.14 To appoint a committee composed of such members of the Board of Trustees and other
experts as it may deem fit and delegate any of its powers, with the exception of rules
19.18 and 19.19, to such committee or the Principal Officer: provided that –
19.14.1 any committee so formed or the Principal Officer must, in the exercise of such powers,
comply with any rules or instructions that may be imposed or issued by the Board of
Trustees; and
19.14.2 any powers delegated as such may at any time be amended or retracted by the Board of
Trustees.
19.15 To authorise the Principal Officer and/or such other members of the Board of Trustees,
upon such conditions as the Board of Trustees may determine, to sign any contract or
other document binding on or relating to Medihelp, or any document authorising the
performance of any act on behalf of Medihelp.
19.16 To transfer to the funds of Medihelp any unclaimed moneys still outstanding after the
expiry of a period of three (3) years from the date of payment.
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19.17 To amend, rescind or add rules, subject to the stipulations of rule 31.
19.18 To implement subscription per benefit option on the basis of the member’s income and/or
the number of dependants, and to decrease or increase subscription to the extent that it
may be deemed necessary to ensure the financial stability of Medihelp, subject to rule
31.1.4.
19.19 To establish or operate, subject to the provisions of any law, on its own or in association
with any other person, any pharmacy, hospital, clinic, maternity home, nursing home,
infirmary, home for aged persons or, with the approval of the Minister, any similar
institution, in the interest of the members of Medihelp.
19.20 To make donations to any hospital, clinic, nursing home, maternity home, infirmary or
home for aged persons, in the interest of the members of Medihelp.
19.21 To enter into agreements with managed healthcare organisations, subject to the Act and
the Regulations.
19.22 To contribute to a fund of any kind whatsoever which is conducted for the benefit of
employees of Medihelp or to pay for insurance policies on the lives of officers of
Medihelp for the benefit of such officers or their dependants.
19.23 To reinsure obligations in terms of the benefits provided for in the Rules: provided that all
such reinsurance arrangements are fully disclosed to the Council for Medical Schemes.
19.24 To introduce, change or abolish benefit options.
20. Indemnity
The Board of Trustees and any employee of Medihelp shall be indemnified by Medihelp against all
legal proceedings, costs and expenses incurred by reason of any claim in connection with the
activities of Medihelp that cannot be ascribed to negligence, dishonesty or fraud.
21. Fidelity Guarantee
The Board of Trustees shall ensure that Medihelp is insured against loss arising from fraud or
dishonesty of any of its employees, including the Board of Trustees, who receives or controls the
funds or securities of Medihelp.
22. Financial Year
The financial year of Medihelp extends over each period of twelve (12) calendar months ending on
31 December.
23. Bank Account
23.1 Medihelp shall maintain a bank account with a registered commercial bank as decided by
the Board of Trustees.
23.2 All moneys received shall be paid into this account and all payments shall be made in
such manner and in such form as stipulated in the Rules.
23.3 Payments from the account shall be authorised by such members of the Board of
Trustees or employees of Medihelp as empowered thereto from time to time by the
Board of Trustees.
24. Custody of Records
24.1 Records of transactions with members must be kept in custody for a period of three (3)
years. All other records must be kept for a period determined by the Board of Trustees.
Rules as registered by the Registrar – Version 4.2010
24.
24.2 Medihelp shall not reply to any enquiry concerning transactions of which the records
have already been destroyed and in such a case Medihelp shall accept no responsibility
for any loss suffered by or obligation imposed on a member.
25. Duties of the Principal Officer and Staff
25.1 The Principal Officer shall ensure that –
25.1.1 the decisions and instructions of the Board of Trustees are executed without
unnecessary delay;
25.1.2 there is proper communication between Medihelp and those parties affected by the
decisions and instructions of the Board of Trustees;
25.1.3 he keeps the Board of Trustees sufficiently and timeously informed of the business of
Medihelp which relates to the duties of the Board of Trustees as stated in section 57(4)
of the Act;
25.1.4 he keeps the Board of Trustees sufficiently and timeously informed of the business of
Medihelp so as to enable the Board of Trustees to comply with the provision of section
57(6) of the Act; and
25.1.5 he does not take any decisions concerning the business of Medihelp without prior
authorisation by the Board of Trustees and that he observes the authority of the Board of
Trustees in its governance of the business of Medihelp.
25.2 The Principal Officer shall be the accounting officer of Medihelp charged with the
collection and depositing of all moneys received and the making of payments authorised
by the Board of Trustees, and shall ensure that proper record is kept of all financial
transactions as well as the assets and liabilities of Medihelp.
25.3 The Principal Officer shall perform the tasks required for the proper administration of the
business of Medihelp and must attend all meetings of Medihelp, the Board of Trustees
and any other properly appointed committee at which his presence is required and he
must ensure that the proceedings at all meetings are properly minuted.
25.4 The Principal Officer must ensure that the financial statements of Medihelp are prepared
and that it complies with the related statutory requirements.
25.5 The Principal Officer shall be responsible to supervise the staff of Medihelp, unless
otherwise decided by the Board of Trustees.
25.6 The staff of Medihelp shall ensure the confidentiality of information concerning the
members of Medihelp and service providers.
25.7 In the absence of the Principal Officer or in the event of him being otherwise unavailable,
an Executive Officer or other duly empowered substitute, appointed by the Board of
Trustees, shall act in his place and perform his duties.
25.8 The Principal Officer can delegate his delegated responsibilities, with the exception of
those as indicated by the Board of Trustees, to any other employee of Medihelp.
26. Auditor and Audit Committee
26.1 An auditor (who must be approved in terms of section 36 of the Act) must be appointed
at each annual general meeting for a period of one (1) year to the conclusion of the next
annual general meeting.
26.2 The following persons shall not be appointed as an auditor of Medihelp –
Rules as registered by the Registrar – Version 4.2010
25.
26.2.1 a person who is a member of the Board of Trustees;
26.2.2 a person who is otherwise employed as an employee, officer or contractor of Medihelp;
26.2.3 a person who is an employee, director, officer or contractor of Medihelp’s administrator,
or of the holding company, subsidiary, joint venture or associate of its administrator;
26.2.4 a person who is not engaged in public practice as an auditor; or
26.2.5 a person who is disqualified from acting as an auditor in terms of the Companies Act,
1973.
26.3 Should an auditor not be appointed or reappointed at the annual general meeting, the
Board of Trustees must, within thirty (30) days of the date of the meeting, appoint an
auditor to fill the vacancy and should it fail to do so, the Registrar of Medical Schemes
may do so at any time.
26.4 Should the appointment of the auditor terminate during the year, the Board of Trustees
shall appoint another auditor within thirty (30) days, and, if it fails to do so, the Registrar
of Medical Schemes may do so at any time. The auditor thus appointed shall relinquish
his office at the conclusion of the first annual general meeting subsequent to his
appointment.
26.5 The auditor of Medihelp shall at all times have the right of access to the books, records,
accounts and documents of Medihelp and is entitled to obtain from the Board of Trustees
and officers of Medihelp such information as he may deem necessary for the
performance of his duties.
26.6 The auditor must report to the members of Medihelp on the accounts examined by him
and on the financial statements submitted to the annual general meeting.
26.7 The Board of Trustees must appoint an audit committee.
27. Annual General Meeting
27.1 The annual general meeting of members shall be held on or before 30 June annually and
shall be convened by the Principal Officer on instruction of the Board of Trustees.
27.2 The notice convening the annual general meeting together with the agenda, annual
report, report by the Board of Trustees which gives an overview of the financial
statements and notice that copies of the most recent annual financial statements will be
dispatched to members on request and are available at Medihelp’s head office and on
Medihelp’s website as stipulated in the Act, proxy form, any notice of motions/proposals
supported by the documentation as contemplated in rule 27.2.2.1, the list of nominated
candidates for election to the Board of Trustees and the curriculum vitae of each
candidate shall be sent to all members, at least thirty (30) days prior to the date of the
meeting, direct or through the medium of their employers: provided that –
27.2.1 the non-receipt of such notice by a member shall not invalidate the proceedings of an
annual general meeting; and
27.2.2 in the event of motions/proposals to be voted on –
27.2.2.1 such notice of motion or proposal is fully documented and motivated; and
27.2.2.2 the motion or proposal must be received by the Principal Officer before the close of
business on the last working day of March annually.
Rules as registered by the Registrar – Version 4.2010
26.
27.3 Thirty-one (31) members of Medihelp present in person at the meeting shall be a
quorum. If a quorum is not present after the lapse of half an hour from the time fixed for
the commencement of the meeting, the meeting shall be postponed until the
corresponding day and time of the following week, and the members then present shall
constitute a quorum: provided that, if the corresponding day of the following week is a
public holiday, the meeting shall be postponed to the first working day thereafter.
27.4 The chairman, or in his absence the vice-chairman of the Board of Trustees shall be
chairman of the annual general meeting. In their absence, the chairman shall be elected
from the members present.
27.5 Subject to the stipulations of rule 29, the annual general meeting or a special general
meeting, as the case may be, must decide on the following matters:
27.5.1 Election of members to the Board of Trustees in terms of rule 17.
27.5.2 Appointment of an auditor in terms of rule 26.
27.5.3 Date of implementation of rule amendments.
27.5.4 Rule amendments as described in rule 31.
27.5.5 Dissolution in accordance with rule 32.
27.5.6 Amalgamations and transfers in accordance with rule 33.
27.5.7 Any other matter which is submitted in terms of the Rules.
27.6 The financial statements and accompanying reports as contemplated in rule 27.2 must
be laid before the meeting.
28. Special General Meeting
28.1 Should the Board of Trustees deem it necessary, or on receipt of a written request,
supported by at least thirty-one (31) members of Medihelp who are entitled to vote, the
Board of Trustees shall, within ninety (90) days of the receipt thereof, convene a special
general meeting. The petition must indicate the matters for discussion and must be
signed by all the petitioners. Only those matters for which the meeting was convened
may be discussed.
28.2 In the case of proposals/motions on which voting is required, the motions/proposals shall
be documented in detail, which complete documentation and motivations shall be
included in the notice of the special annual general meeting which must be circulated to
all members.
28.3 Notice of a special general meeting must be sent to all members, together with the
agenda and form of proxy and the documentation contemplated in rule 28.2, if voting on
matters is required, at least thirty (30) days before the day of the meeting, either direct or
through the medium of their employers.
28.4 Thirty-one (31) members of Medihelp who are entitled to vote and present in person at
the meeting shall be a quorum. If a quorum is not present after the lapse of half an hour
from the time fixed for the commencement of the meeting, the meeting shall be
postponed until the corresponding day and time of the following week and the members
present shall constitute a quorum: provided that –
28.4.1 if the corresponding day of the following week is a public holiday, the meeting shall be
postponed to the first working day thereafter; and
Rules as registered by the Registrar – Version 4.2010
27.
28.4.2 if a quorum is not present after the lapse of half an hour from the time fixed for the
commencement of a meeting convened on request of the members, the meeting shall be
considered cancelled.
29. Voting at General Meetings
29.1 Every member whose subscriptions are paid up and who is present at an annual general
meeting or special general meeting shall be entitled to vote or may, subject to this rule,
appoint another member of the Scheme as a proxy to attend, speak and vote at the
meeting in his stead as indicated in the proxy form. In the event of voting by means of a
ballot, every member present in person or represented by a proxy shall be entitled to
vote. The chairman shall have a normal as well as a casting vote.
29.2 Election of members to the Board of Trustees shall, when a vote is necessary, take place
by means of a ballot. The names of the candidates shall be entered in alphabetical order
on the ballot papers and a vote shall be recorded by making a cross against the name of
each candidate for whom a vote is cast. Voting and the counting of votes shall be
executed in accordance with the procedure as set out in Schedule E. A ballot paper shall
be considered spoilt in its entirety if –
29.2.1 the form is submitted without any votes indicated;
29.2.2 it is not signed; or
29.2.3 it is not completed in ink,
and in respect of a particular item to be voted on, the vote in respect of the item shall be
spoilt if the member who casts the vote –
29.2.4 exercised more choices than the number of options permitted on the ballot paper; and/or
29.2.5 alters his choice but fails to initial the alteration.
29.3 Voting during the meeting on administrative arrangements for holding the meeting shall
only be by members who are entitled to vote and present in person at the meeting, and
shall be by the show of hands.
29.4 Resolutions adopted at a general meeting shall be binding on all members of Medihelp.
Proxy
29.5 The document (hereafter referred to as the form of proxy) to appoint a person to act as
proxy must meet the following requirements, failing which the proxy shall be invalid in its
entirety. The form of proxy should be –
29.5.1 in writing;
29.5.2 completed and signed by the warrantor;
29.5.3 signed by the person who acts as proxy; and
29.5.4 in the format as determined by the Board of Trustees.
29.6 A person who acts as proxy must be a member of Medihelp and must be entitled to vote
at any annual general meeting or special general meeting.
29.7 The original form of proxy must be delivered to the nominated office at least five (5)
working days before the time for holding the annual general meeting or the special
general meeting on which the warrantor wants to vote. Should a member fail to comply
with this provision, the form of proxy shall not be considered valid.
Rules as registered by the Registrar – Version 4.2010
28.
29.8 For the purpose of rule 29.7 a working day shall be deemed to exclude Saturdays,
Sundays and public holidays.
30. Settlement of Complaints and Disputes
30.1 Members may lodge their complaints, in writing, to Medihelp, which complaints shall be
responded to by Medihelp in writing within thirty (30) days.
30.2 The Principal Officer shall refer any dispute arising between Medihelp and a member or
former member or prospective member out of the administration and decisions of
Medihelp to the Disputes Committee for settlement.
30.3 The Disputes Committee comprising three (3) committee members, of which at least one
(1) committee member must be a person with legal expertise, shall be convened from a
panel of persons appointed by the Board of Trustees for a period of one (1) year, which
members of the committee shall not be members of the Board of Trustees, employees of
Medihelp or employees of the administrator of Medihelp: provided that the committee
members shall be remunerated as determined by the Board of Trustees for attending a
sitting of the committee.
30.4 On receipt of a request for the settlement of a dispute, the Principal Officer shall convene
a meeting of the Disputes Committee by giving not less than twenty-one (21) days’ notice
in writing prior to the meeting to the complainant and all the persons serving on the
Disputes Committee, stating the date, venue and particulars of the dispute.
30.5 A dispute must be submitted to the Principal Officer, fully documented by the person
concerned and the discrepancy out of the administration and decisions of Medihelp must
be reasoned out in terms of the Rules.
30.6 The Disputes Committee shall determine the procedure to be followed when hearing the
dispute.
30.7 The parties to the dispute have the right to be heard at the proceedings, either in person
or through a representative.
30.8 An aggrieved person shall have the right to appeal to the Council for Medical Schemes
against the decision of the Disputes Committee, which appeal shall be in the form of an
affidavit directed to the Council for Medical Schemes and shall be furnished to the
Registrar of Medical Schemes within three (3) months after the date on which the
decision of the Disputes Committee was made.
31. Amendment of Rules
31.1 The Board of Trustees has the authority to amend or delete any rule and any Schedule
to the Rules, or to implement new rules and Schedules to the Rules: provided that –
31.1.1 no amendment, deletion or addition to the Rules pertaining to the objectives of Medihelp
shall be valid unless it has been approved by the majority of members who are entitled to
vote, who are either present in person or by proxy at the annual general meeting or
special general meeting;
31.1.2 the correction of any error of spelling, language, translation, punctuation or grammatical
errors in the Rules, rearranging and renumbering of rules shall not be regarded as being
an amendment or rescission of, or addition to the Rules;
Rules as registered by the Registrar – Version 4.2010
29.
31.1.3 no amendment, rescission or addition to rules 16 (LIABILITY OF MEMBERS AND
PARTICIPATING EMPLOYERS), 17 (GOVERNANCE), 18 (DUTIES OF THE BOARD
OF TRUSTEES), 19 (POWERS OF THE BOARD OF TRUSTEES), 26 (AUDITOR AND
AUDIT COMMITTEE), 27 (ANNUAL GENERAL MEETING), 28 (SPECIAL GENERAL
MEETING), 29 (VOTING AT GENERAL MEETINGS), 30 (SETTLEMENT OF
COMPLAINTS AND DISPUTES), 32 (DISSOLUTION) and 33 (AMALGAMATION AND
TRANSFER) shall be valid unless it has been approved by two-thirds of the members
who are entitled to vote, who are either present in person or by proxy at a general
meeting; and
31.1.4 no amendment, rescission or addition shall be valid unless it has been approved by the
Registrar of Medical Schemes.
31.2 A member must, within sixty (60) days after the registration of a rule amendment, be
informed in writing of such registration, and in case of an amendment of a member’s
rights, responsibilities, subscription, the benefits to which he is entitled or any other
condition affecting his membership, he shall be informed in writing at least thirty (30)
days before implementation: provided that the non-receipt of notification of a rule
amendment shall in no way relieve a member of any obligations that may arise from such
amendment.
31.3 Notwithstanding the stipulations of rule 31.1 the Board of Trustees must, on request and
to the satisfaction of the Registrar of Medical Schemes, amend any rule that is contrary
to the stipulations of the Act.
32. Dissolution
32.1 The Scheme may be dissolved by order of a competent court or by voluntary dissolution.
32.2 The members at a general meeting of Medihelp may decide that the Scheme must be
dissolved, in which event the Board of Trustees must arrange for members to decide by
ballot whether Medihelp must be liquidated.
32.3 Pursuant to a decision by members taken in terms of rule 32.2, the Principal Officer, in
consultation with the Registrar of Medical Schemes, must furnish every member with a
memorandum explaining the reasons for the proposed dissolution and setting forth the
proposed basis of distribution of the assets in the event of winding up, together with a
ballot paper.
32.4 Every member must be requested to return his ballot paper duly completed before a set
date. If at least fifty (50) per cent of the members return their ballot papers duly
completed and if the majority thereof is in favour of the dissolution of the Scheme, the
Board must ensure compliance therewith and appoint, subject to the approval of the
Registrar of Medical Schemes, a competent person as liquidator.
33. Amalgamation and Transfer
33.1 Medihelp may, subject to the provisions of section 63 of the Act, amalgamate with,
transfer its assets and liabilities to, or take transfer of assets and liabilities of any other
medical scheme or person, in which event the following process shall be followed: If the
Board of Trustees is of the opinion that Medihelp should amalgamate or transfer, the
Principal Officer shall, on instruction of the Board of Trustees, send to every member,
direct or through the medium of his employer, a memorandum setting out the reasons for
such action together with a ballot paper: provided that the non-receipt by a member of
the said memorandum and ballot paper shall not invalidate any action taken in terms of
this paragraph. Every member shall be requested to return his ballot paper properly
completed before a fixed date. If the majority of the properly completed ballot papers
returned to Medihelp are in favour of amalgamation or transfer, the Board of Trustees
shall take a formal decision to amalgamate or transfer.
Rules as registered by the Registrar – Version 4.2010
30.
33.2 If a decision to amalgamate or transfer has been taken in accordance with rule 33.1, the
amalgamation or transfer shall be concluded in terms of the stipulations of section 63 of
the Act.
34. Right To Obtain Documents And Inspection Of Documents
34.1 A beneficiary must on request be supplied with the following documents –
34.1.1 the Rules of Medihelp;
34.1.2 the latest audited annual financial statements, returns, Board of Trustees’ report and
auditor’s report; and
34.1.3 accompanying management accounts in respect of the various benefit options of
Medihelp.
34.2 A beneficiary is entitled to inspect at the registered office of Medihelp any document
referred to in rule 34.1 and to make extracts therefrom.
Rules as registered by the Registrar – Version 4.2010
31.
MEDIHELP RULES: SCHEDULEA
Subscriptions, Contributions to a Personal Medical Savings Account and
Penalties for Persons Joining Late in Life
Subscriptions
1. The subscriptions stated in paragraph 2, together with the contribution to the personal
medical savings account contemplated in paragraph 3, as well as any applicable
subscription penalty contemplated in paragraph 5, shall be payable per calendar month
or part thereof.
2. Monthly subscriptions for the various benefit options, including the contribution to the
personal medical savings account, are as follows with effect from 1 January 2010:
MEDIHELP
PLUS
DIMENSION
ELITE
DIMENSION
PRIME 3
DIMENSION
PRIME 2
DIMENSION
PRIME 1
Member R3,600 R1,800 R1,320 R1,098 R762
Dependant R3,600 R1,680 R1,134 R912 R624
Dependent child younger
than 26 years R894 R486 R396 R336 R234
UNIFY
Monthly income R3,000 and less R3,001 to R5,000 R5,001 to R7,000 R7,001 to R9,000 R9,001 and more
Member R923 R1,030 R1,238 R1,335 R1,649
Dependant R720 R942 R1,164 R1,217 R1,270
Dependent child younger
than 24 years R106 R120 R151 R160 R166
NECESSE
Member R642
Dependant R504
Dependent child younger
than 21 years R276
2.1 In the case of the Dimension Prime 1, 2 and 3 benefit options subscriptions are payable
in respect of dependent children younger than 26 years, to a maximum of two (2)
registered children, irrespective of the number of such children registered.
2.2 In those cases where the subscriptions for a benefit option are based on income, proof of
monthly income must be supplied to Medihelp in a manner which is acceptable to
Medihelp. If acceptable proof of income is not supplied, subscriptions shall be calculated
according to the next highest income category. Should proof of income be supplied at a
later stage, subscriptions shall be adjusted from a current date with effect from the month
following the month in which proof of income is supplied: provided that the Principal
Officer may, in his sole discretion, decide on a different date.
Contributions to a personal medical savings account
3. The monthly contributions to the personal medical savings account which are included
with the monthly subscriptions are as follows with effect from 1 January 2010:
Rules as registered by the Registrar – Version 4.2010
32.
DIMENSION PRIME 2
Member R216.00
Dependant R180.00
Dependent child younger
than 26 years R66.00
4. A personal medical savings account is only applicable in the case of the Dimension
Prime 2 benefit option.
Subscription penalties for persons joining late in life
5. Should a late-joiner penalty be applied to a beneficiary, the applicable penalty band, as
explained in paragraph 5, shall be calculated according to the following formula:
5.1 Penalty band = B minus (35 + C), where –
5.1.1 “B” means the age of the late joiner at the time of his enrolment as a beneficiary; and
5.1.2 “C” means the proven number of completed 12-month periods of membership of one or
more medical schemes.
6. Table of penalty bands and maximum subscription penalty:
PENALTY BANDS SUBSCRIPTION PENALTY
1 to 4 years 0.05 of subscription
5 to 14 years 0.25 of subscription
15 to 24 years 0.50 of subscription
25 years and more 0.75 of subscription
7. For the purpose of producing evidence of previous membership, it shall be sufficient
proof if the beneficiary produces a statement in which he declares –
7.1 the name or names of the relevant medical schemes and the relevant periods in which
he was a registered beneficiary; and
7.2 the reasonable efforts that have been made to obtain documentary evidence of such
membership, but have been unsuccessful.
8. Where a beneficiary produces acceptable evidence of previous membership as a
beneficiary to Medihelp after a late-joiner penalty has been imposed, Medihelp must
recalculate the late-joiner penalty and apply such revised penalty, if any, from the
beginning of the calendar month following the month in which such evidence is received
by Medihelp: provided that if proof is provided within six (6) months after enrolment, the
excess penalties levied may be refunded to the member.
9. Medihelp shall continue to apply a late-joiner penalty that was applied to a beneficiary on
his enrolment at the medical scheme from which the beneficiary transfers to Medihelp.
Rules as registered by the Registrar – Version 4.2010
33.
MEDIHELP RULES: SCHEDULEB
Services and the Maximum and Minimum Granting of Benefits
and Interchange between Benefit Options with effect from 1 January 2010
1. With the exception of the exclusions listed in Schedule C, Schedule C.1 and Schedule
C.2, Medihelp shall grant benefits per benefit option in respect of services rendered as
set out in Schedules B1 to B7.
2. Where a maximum amount is imposed on benefits payable during a financial year –
2.1 benefits shall be calculated on the services rendered during the financial year concerned,
and no adjustments by means of debiting a claim against a preceding or following
financial year, shall be made;
2.2 such maximum amount and the savings protector, excluding maximum benefits applied
per case, shall be calculated on a pro rata basis from the date of enrolment as a
beneficiary to the end of the financial year;
2.3 any unexpended benefits shall not, in the event of a change of benefit option, be
transferred from the previous to the next benefit option(s); and
2.4 the application of maximum benefits shall mean the following: provided that the balance
available for any benefit at the end of a financial year may not be carried forward to the
following financial year:
2.4.1 “Per family” shall mean a member and all his registered dependants collectively.
2.4.2 “Per beneficiary” shall mean each individual beneficiary separately.
2.4.3 “Per case” shall mean –
2.4.3.1 in relation to an implanted prosthesis, the total cost of all the components of every
complete prosthesis;
2.4.3.2 in relation to emergency transport services, every occasion which requires a beneficiary
to be transported by means of emergency transport for reasons which are medically
justified; and
2.4.3.3 in relation to a sex change operation, every occasion on which a surgical intervention
takes place.
2.4.4 “Pooled benefit” shall mean the total rand value of the benefit per beneficiary multiplied
by the number of beneficiaries, which is available for any of the beneficiaries, irrespective
of which beneficiary uses the benefit.
2.4.5 “Cycle” shall mean the stated length of the benefit cycle calculated in relation to any
period of uninterrupted membership of Medihelp, regardless of any interchange between
benefit options during such uninterrupted period of membership of Medihelp.
3. Interchange between benefit options
3.1 Interchange between benefit options may only occur with effect from the beginning of the
subsequent financial year, if Medihelp receives the member’s written request before
1 December: provided that Medihelp, at its own discretion, may approve the interchange
between benefit options where groups or individuals request such change in writing to be
implemented with effect from a date determined by Medihelp.
Rules as registered by the Registrar – Version 4.2010
34.
3.2 In the case of a beneficiary who is diagnosed for the first time with a chronic condition for
which his present benefit option offers insufficient or no benefits, such member may
apply to change to the Medihelp Plus benefit option, subject to the following conditions:
3.2.1 The request for interchange must reach Medihelp within 60 days after the chronic
condition was diagnosed.
3.2.2 The request for interchange must be accompanied by –
3.2.2.1 A description of the chronic condition, including the ICD-10 code;
3.2.2.2 the date on which the condition was first diagnosed;
3.2.2.3 the applicable medical reports supporting the diagnosis;
3.2.2.4 the treatment received since the condition was first diagnosed; and
3.2.2.5 the prescribed future treatment plan, including a completed MEDICHRON application
form should chronic medicine be prescribed.
3.2.3 If approved, the benefit option of the member and his dependants shall change from the
beginning of the month following the month in which the application was received.
4. Protocols
4.1 Medihelp shall allocate benefits according to the protocol(s) that apply for the following,
which protocols are available on request: provided that co-payments shall apply per
benefit option, as per paragraph 5 of Schedule B, for the treatment of non-PMB
conditions, if the treatment voluntarily deviates from the applicable protocol(s) or services
are voluntarily obtained outside the designated service provider network. In the case of
Prescribed Minimum Benefits, the co-payments as explained in Annexure 2 shall be
applicable:
4.1.1 Treatment of chronic renal failure.
4.1.2 Private nursing.
4.1.3 EVARS prostheses.
4.1.4 Oncology.
4.1.5 Prescribed minimum benefits.
4.1.6 Medicine used for indications other than for what it has been registered by the South
African Medicines Control Council.
4.1.7 Positron Emission Tomography (PET).
4.1.8 Back treatment programme as a prerequisite for spinal column surgery.
4.1.9 The optical benefit is subject to the following clinical rules:
4.1.9.1 No single vision prescription < 0.50 dioptre will be paid or considered for payment.
4.1.9.2 No bifocal/varifocal adds for less than 1 dioptre will be paid of considered for payment.
4.1.9.3 Bifocal/varifocal lenses for adults under the age of 40 years old must be motivated.
Rules as registered by the Registrar – Version 4.2010
35.
4.1.9.4 No varifocals for children under the age of 18 years will be paid or considered for
payment, with the exception of post-cataract surgery. Bifocals to be considered for
children under the age of 18 years on motivation only.
4.1.9.5 No contact lenses for children under the age of 16 years, unless motivated.
4.1.9.6 Motivations are required for composite consultations performed on children under the
age of five years old.
4.1.9.7 Vertical prism > 1 dioptre should be motivated.
4.1.9.8 An additional lens benefit to a maximum of once per 12-month period may, in the sole
discretion of the contracted service provider, be considered in cases where progressive
myopia can be demonstrated and motivated, and post-cataract surgery, provided in both
instances that the prescription has changed by 0.50 dioptres or more.
Rules as registered by the Registrar – Version 4.2010
36.
5. Applicable co-payments
( See PDF Document )

MEDIHELP RULES: SCHEDULEC
Benefit Exclusions with effect from 1 January 2010
The following shall be excluded from benefits, except in the case of statutory prescribed minimum
benefits, subject to the stipulations of rule 8.1:
1. General
1.1 Services which are not mentioned in the Rules as well as services which in the opinion of the
Board of Trustees, are not aimed at the generally accepted medical treatment of an actual or a
suspected sickness or handicap, which is harmful or threatening to necessary bodily functions
(the process of ageing is not considered to be a sickness or handicap).
1.2 Travelling and accommodation costs, including meals as well as administration costs of a
member and/or service provider.
1.3 Aptitude and intelligence tests.
1.4 Operations, treatments and procedures –
1.4.1 of own choice;
1.4.2 for cosmetic purposes;
1.4.3 for refractive surgery not approved beforehand by Medihelp; and
1.4.4 for the treatment of obesity, with the exception of the treatment of obesity which is motivated by
a medical specialist as life-threatening and approved beforehand by Medihelp.
1.5 Treatment of wilfully self-inflicted injuries, unless it is a prescribed minimum benefit.
1.6 The treatment of infertility, other than the following treatment (according to PMB code 902M),
subject to pre-authorisation by Medihelp:
1.6.1 Hysterosalpinogram.
1.6.2 The following blood tests:
• Day 3 FSH / LH;
• Oestradiol;
• Thyroid function (TSH);
• Prolactin;
• Rubella;
• HIV;
• VDRL;
• Chlamydia; and
• Day 21 progesterone.
1.6.3 Laparoscopy.
1.6.4 Hysteroscopy.
1.6.5 Surgery (uterus and tubal).
1.6.6 Manipulation of ovulation defects and deficiencies.
1.6.7 Semen analysis (volume, count, mobility, morphology, MAR-test).
1.6.8 Basic counselling and advice on sexual behaviour, temperature charts, etc.
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39.
1.6.9 Treatment of local infections.
1.7 The artificial insemination of a person as defined in the National Health Act, 2003 (Act No 61 of
2003).
1.8 Immunisation (including immunisation procedures and material) which is required by an
employer, excluding flu immunisations and standard child immunisations on the Dimension
Prime benefit range.
1.9 Bandages, cotton wool and plasters on prescription that are not used by a supplier of service
during a treatment/procedure.
1.10 Services which are claimable from the Compensation Commissioner, an employer or any other
party, subject to the stipulations of rule 15.4.
1.11 Treatment of alcoholism and drug abuse as well as services rendered by institutions which are
registered in terms of section 21(2) of the Abuse and Dependence-producing Substances
and Rehabilitation Centres Act, 1971 (Act No 41 of 1971) or other institutions whose services
are of a similar nature, except in the following instance when alcohol and drug abuse will be
considered as a Prescribed Minimum Benefit:
Code Diagnosis Treatment
182T
Abuse or dependence on
psychoactive substance,
including alcohol
Hospital based management up to three
weeks per benefit year
910T
Acute delusional mood, anxiety,
personality, perception disorder
and organic mental disorder
caused by drugs
Hospital based management up to three
weeks per benefit year
910T Alcohol withdrawal delirium;
alcohol intoxication delirium
Hospital based management up to three
days leading to rehabilitation
910T Delirium: amphetamine, cocaine,
or other psychoactive substance
Hospital based management up to three
days
1.12 Exercise, guidance and rehabilitation programmes.
1.13 Treatment of impotence.
1.14 Treatment of occupational diseases.
1.15 Services rendered by social workers.
1.16 Completion of medical and other questionnaires not requested by Medihelp.
1.17 Costs for evidence in a lawsuit.
1.18 Costs of visits at home and home programmes.
1.19 Costs exceeding the guideline tariff for a service or the maximum benefit limit to which a
member is entitled, subject to Annexure 2.
1.20 Food substitutes, food supplements and patent food, including baby food.
1.21 Multivitamin and multi-mineral supplements alone or in combination with stimulants (tonics).
1.22 Slimming remedies, provided that benefits shall be considered if motivated by a medical
specialist as life-essential to be used for a limited period, and if approved beforehand by the
Principal Officer.
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40.
1.23 All patent substances, suntan lotions, anabolic steroids, as well as substances not registered by
the South African Medicines Control Council, except in the case of medicine items approved by
Medihelp in the following instances –
1.23.1 medicine items with patient-specific exemptions in terms of section 21 of the Medicines and
Related Substances Control Act, 1965 (Act No 101 of 1965) as amended;
1.23.2 homeopathic and naturopathic medicine items that have valid NAPPI codes as well as
compounded non-proprietary medicine items dispensed by a homeoparth/naturopath; and
1.23.3 where well-documented, sound evidence-based proof exists of efficacy and cost-effectiveness.
1.24 When only accommodation and/or general care services are rendered.
1.25 The cost of transport with an ambulance/emergency vehicle –
1.25.1 from a hospital/other institution to a residence;
1.25.2 in the event of a self-inflicted injury, unless it is a prescribed minimum benefit;
1.25.3 in the event of a visit to friends/family; and
1.25.4 to the rooms of a medical practitioner when the objective of the visit/consultation/treatment does
not pertain to admission in a hospital.
1.26 The cost of harvesting and/or preserving human tissues, including, but not limited to, stem cells,
for future use thereof to treat a medical condition which has not yet been diagnosed in a
beneficiary.
1.27 Dental services:
1.27.1 Oral hygiene instructions.
1.27.2 Nutritional and tobacco counselling.
1.27.3 Caries susceptibility and microbiotical tests.
1.27.4 Electrognathographic recordings and other such electronic analyses.
1.27.5 Fissure sealants on patients older than 16 years.
1.27.6 Root canal treatment on third molars (wisdom teeth) and primary teeth.
1.27.7 Pulp capping (direct and indirect).
1.27.8 Polishing of restorations.
1.27.9 Ozone therapy.
1.27.10 Metal base to full dentures, including the laboratory cost.
1.27.11 Soft base to new dentures.
1.27.12 Diagnostic dentures.
1.27.13 Provisional crowns.
1.27.14 Laboratory cost of provisional and emergency crowns.
1.27.15 Resin bonding for restorations charged as a separate procedure.
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41.
1.27.16 Dental bleaching.
1.27.17 Porcelain veneers and inlays.
1.27.18 Metal, porcelain or resin inlays, except where such inlays form part of a bridge.
1.27.19 Crown on third molar (wisdom teeth).
1.27.20 Pontics on second molars.
1.27.21 Laboratory fabricated crowns on primary teeth.
1.27.22 Fixed prosthodontics (crowns) used to repair teeth damaged due to bruxism (tooth grinding),
toothbrush abrasion or attrition, erosion or fluorosis.
1.27.23 Perio chip.
1.27.24 Apisectomies in hospital.
1.27.25 Dentectomies in hospital.
1.27.26 Frenectomies in hospital.
1.27.27 In-hospital soft tissue impactions.
1.27.28 In-hospital single impacted tooth.
1.27.29 Conservative dental treatment (fillings, extractions and root canal therapy) in hospital for adults.
1.27.30 Professional oral hygiene procedures in hospital.
1.27.31 Hospitalisation for dental implantology and surgery related to dental implantology.
1.27.32 Hospitalisation for surgical tooth exposure for orthodontic reasons.
1.27.33 Orthognathic (jaw correction) surgery and the related hospital cost.
1.27.34 Sinus lifts.
1.27.35 Bone augmentations.
1.27.36 Bone and other tissue regeneration procedures.
1.27.37 Gingivectomy.
1.27.38 Periodontal flap surgery, tissue grafting and hemisection of a tooth.
1.27.39 Orthodontic re-treatment.
1.27.40 Lingual orthodontics.
1.27.41 Dolder bars and associated abutments on implants (including the laboratory cost).
1.27.42 Laboratory costs, where the associated dental treatment is not covered.
1.27.43 Laboratory cost associated with mouth guards (including material cost).
1.27.44 Snoring appliances.
1.27.45 High-impact acrylic.
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42.
1.27.46 Cost of mineral trioxide.
1.27.47 Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments.
1.27.48 Cost of gold, precious metal, semi-precious metal and platinum foil.
1.27.49 Cost of invisible retainer material.
1.27.50 Cost of bone regeneration material.
1.27.51 Replacement of amalgam (silver) fillings with composite (white) fillings.
1.27.52 Professionally applied topical fluoride in adults.
1.27.53 Laboratory delivery fees.
1.27.54 Cost of dental materials in hospital.
1.27.55 IV conscious sedation for dental implantology in hospital.
1.27.56 Fixed prosthodontics used to restore teeth for cosmetic reasons.
1.27.57 Fixed prosthodontics where a reasonable attempt has not been made to restore/replace the
tooth conservatively.
1.27.58 Fixed prosthodontics where the patient’s mouth is periodontally compromised.
1.27.59 Fixed prosthodontics where the tooth has been recently restored to function.
1.27.60 Fixed prosthodontics (crowns) where the tooth is unopposed/non-functional.
1.27.61 Surgical periodontics.
1.27.62 Mutliple hospital admissions for the same dental treatment.
2. Procedures and medicines excluded from benefits for the Dimension Elite benefit option
(Schedule B2), unless it is a prescribed minimum benefit:
2.1 Breast augmentation.
2.2 Breast reduction.
2.3 Gastroplasty.
2.4 Sex reversal operations.
2.5 Lipectomy.
2.6 Epilation.
2.7 Otoplasty/reconstruction of the ear.
2.8 Refractive procedures.
2.9 Obesity.
2.10 All biological and other medicine items as per Medihelp’s medicine exclusion list, unless when
indicated and prescribed for the treatment of a PMB condition.
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43.
3. Procedures and medicines excluded from benefits for the Dimension Prime benefit
options (Schedule B3, Schedule B4 and Schedule B5), unless it is a prescribed minimum
benefit:
3.1 Hip, knee and shoulder replacements
3.2 Breast augmentation.
3.3 Breast reduction.
3.4 Gastroplasty.
3.5 Sex reversal operations.
3.6 Lipectomy.
3.7 Epilation.
3.8 Otoplasty/reconstruction of the ear.
3.9 Refractive procedures.
3.10 Obesity.
3.11 All biological and other medicine items as per Medihelp’s exclusion list, unless when indicated
and prescribed for the treatment of a PMB condition.
4. Additional to the exclusions listed in paragraph 3 above, the following procedures are
also excluded from benefits for the Dimension Prime 1 benefit option (Schedule B5):
4.1 Hymenectomy.
4.2 Circumcision.
Rules as registered by the Registrar – Version 4.2010
44.
MEDIHELP RULES: SCHEDULE C.1
Benefit Exclusions with effect from 1 January 2010
for the Necesse benefit option
The following shall be excluded from benefits, except in the case of statutory prescribed minimum
benefits, subject to the stipulations of rule 8.1:
1. General
1.1 Services which are not mentioned in the Rules as well as services which in the opinion of the
Board of Trustees, are not aimed at the generally accepted medical treatment of an actual or a
suspected sickness or handicap, which is harmful or threatening to necessary bodily functions
(the process of ageing is not considered to be a sickness or handicap).
1.2 Healthcare services required during a compulsory waiting period, as underwritten by the
Scheme.
1.3 Travelling and accommodation costs, including meals as well as administration costs of a
member and/or service provider.
1.4 Aptitude and intelligence tests.
1.5 Operations, treatments and procedures –
1.5.1 of own choice;
1.5.2 for cosmetic purposes;
1.5.3 for refractive surgery not approved beforehand by Prime Cure; and
1.5.4 for the treatment of obesity, with the exception of the treatment of obesity which is motivated by
a medical specialist as life-threatening and approved beforehand by Prime Cure.
1.6 All slimming remedies and preparations to treat obesity.
1.7 Contact lenses and contact lens solutions.
1.8 Food substitutes and supplements, including baby food and special milk preparations.
1.9 Homeopathic and herbal medicine, as well as household remedies or any other miscellaneous
household product of a medicinal nature.
1.10 Medicine for the treatment of alcoholism and dependence-forming substances, unless it is a
prescribed minimum benefit.
1.11 Anabolic steroids.
1.12 Roaccutane and Retin A, or any skin lightening agents.
1.13 Wilfully self-inflicted injuries and illnesses, unless it is a prescribed minimum benefit.
1.14 Recuperative treatment of any nature.
1.15 Injuries sustained during participation in a strike, unlawful demonstration, unrest or violent
conduct, except in the case of a prescribed minimum benefit.
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45.
1.16 Services rendered to beneficiaries outside the Prime Cure network, except for those services as
listed in Schedule B6 or if voluntarily obtained from a non-designated service provider in the
case of a PMB condition.
1.17 Stimulant laxatives, unless pre-authorised.
1.18 The cost of reports, examinations and tests for insurance policies and for legal reasons.
1.19 Acupuncture, biokinetic, chiropractic, herbalist, naturopathic and homeopathic services.
1.20 Back and neck fusion, unless it is a prescribed minimum benefit.
1.21 Joint replacement, unless it is a prescribed minimum benefit.
1.22 The artificial insemination of a person as defined in the National Health Act, 2003 (Act No 61 of
2003).
1.23 Immunisation (including immunisation procedures and material) which is required by an
employer, excluding flu immunisations.
1.24 Bandages, cotton wool and plasters on prescription that are not used by a supplier of service
during a treatment/procedure.
1.25 Services which are claimable from the Compensation Commissioner, an employer or any other
party, subject to the stipulations of rule 15.4.
1.26 Treatment of alcoholism and drug abuse as well as services rendered by institutions which are
registered in terms of section 21(2) of the Abuse and Dependence-producing Substances
and Rehabilitation Centres Act, 1971 (Act No 41 of 1971) or other institutions whose services
are of a similar nature, except if alcohol and drug abuse will be considered as a Prescribed
Minimum Benefit.
1.27 Exercise, guidance and rehabilitation programmes.
1.28 Treatment of impotence.
1.29 Treatment of occupational diseases, unless a PMB.
1.30 Services rendered by social workers.
1.31 Completion of medical and other questionnaires not requested by Medihelp.
1.32 Costs for evidence in a lawsuit.
1.33 Costs exceeding the guideline tariff for a service or the maximum benefit limit to which a
member is entitled, subject to Annexure 2.
1.34 Multivitamin and multi-mineral supplements alone or in combination with stimulants (tonics),
unless a PMB.
1.35 All patent substances, suntan lotions, anabolic steroids, as well as substances not registered by
the South African Medicines Control Council, except in the case of medicine items approved by
Prime Cure in the following instances –
1.35.1 medicine items with patient-specific exemptions in terms of section 21 of the Medicines and
Related Substances Control Act, 1965 (Act No 101 of 1965) as amended; and
1.35.2 where well-documented, sound evidence-based proof exists of efficacy and cost-effectiveness.
1.36 When only accommodation and/or general care services are rendered (frail care).
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46.
1.37 The cost of transport with an ambulance/emergency vehicle to the rooms of a medical
practitioner when not medically required and when the objective of the
visit/consultation/treatment does not pertain to admission in a hospital
1.38 The cost of harvesting and/or preserving human tissues, including, but not limited to, stem cells,
for future use thereof to treat a medical condition which has not yet been diagnosed in a
beneficiary.
1.39 All biological and other medicine items as per Medihelp’s exclusions list, unless when indicated
and prescribed for the treatment of a PMB condition.
1.40 Dental services:
1.40.1 Dental extractions for non-medical reasons.
1.40.2 Provision for gold inlays in dentures.
1.40.3 Oral hygiene instructions.
1.40.4 Nutritional and tobacco counselling.
1.40.5 Caries susceptibility and microbiological tests.
1.40.6 Electrognathographic recordings and other such electronic analyses.
1.40.7 Fissure sealants on patients older than 16 years.
1.40.8 Root canal treatment, crowns, bridges and other advanced or specialised dentistry.
1.40.9 Root canal treatment on third molars (wisdom teeth) and primary teeth.
1.40.10 Pulp capping (direct and indirect).
1.40.11 Polishing of restorations.
1.40.12 Fluoride treatment of patients 12 years and older, unless pre-authorised.
Rules as registered by the Registrar – Version 4.2010
47.
MEDIHELP RULES: SCHEDULE C.2
Benefit Exclusions with effect from 1 January 2010
for the Unify benefit option
The following, together with the exclusions listed in Schedule C, shall be excluded from benefits, except in
the case of statutory prescribed minimum benefits, subject to the stipulations of rule 8.1:
1. General
1.1 The cost for hiring and purchasing medical, surgical, orthopaedic and other appliances,
including surgical stockings.
1.2 The treatment of acne and skin conditions.
1.3 Patent medicine, beauty preparations, bandages, cotton wool and similar material, patent foods
including baby food, contraceptives and apparatus to prevent pregnancies, tonics, slimming
preparations, household and biochemical remedies, contact lens solutions, homeopathic
medicine, vitamins, and any drug or remedies not registered with the SA Medicines Control
Council or similar institution.
1.4 All costs related to the treatment of sickness conditions that were specifically excluded from
benefits when the beneficiaries joined the Scheme as per the waiting periods.
1.5 The cost of medicine purchased from a person not legally entitled to supply or prescribe
medicine.
1.6 Any expenses incurred by a beneficiary in respect of general practitioner services, procedures
and dispensed medicine other than those services provided by the beneficiary’s selected
general practitioner, and other than the out-of-area benefits, subject to Annexure 2.
1.7 Any expenses incurred by a beneficiary in respect of optical and dental services, other than the
services provided by the beneficiary’s selected optometrist/dentist.
1.8 The cost of any services rendered by a specialist without recommendation and/or referral of the
beneficiary’s selected general practitioner, subject to Annexure 2.
1.9 Appointments cancelled and/or not kept.
1.10 The cost involved in any surgical procedure, treatment, equipment, agent or medicine of
experimental nature.
1.11 The treatment of snoring, rhinoplasty, mammoplasty or uvulopalatopharyngioplasty.
1.12 Immunisations normally available from State facilities and anti-malaria agents used as
prophylaxis against malaria.
1.13 Injuries sustained during participation in a strike, unlawful action, revolt or violent behaviour.
1.14 All biological and other medicine items as per Medihelp’s exclusion list, unless when indicated
and prescribed for the treatment of a PMB condition.
Rules as registered by the Registrar – Version 4.2010
48.
MEDIHELP RULES: SCHEDULED
Emergency Transport Services and Transport of Blood and Medicine
1. Scope of services
1.1 As from 1 January 2010 beneficiaries are entitled to the following benefits for services rendered
by Netcare 911, subject to the benefit exclusions stated in paragraph 3 of this Schedule.
1.1.1 Emergency medical assistance during emergency transport or relocation
Medihelp Plus, Dimension Elite and Dimension Prime benefit options:
1.1.1.1 The transport of a beneficiary, being a resident of South Africa, Swaziland, Lesotho, Namibia
and Mozambique, to the nearest, most appropriate medical facility equipped for the patient’s
specific emergency medical condition, if recommended and authorised by the staff of Netcare
911: provided that the emergency occurs within the beneficiary’s land of residence.
1.1.1.2 In case of the emergency occurring outside the borders of the beneficiary’s land of residence,
the limit for transport outside the borders, as per Schedules B1, B2, B3, B4 and B5, will apply.
Unify benefit option:
1.1.1.3 The transport of a beneficiary, being a resident of South Africa, to the nearest, most appropriate
medical facility equipped for the patient’s specific emergency medical condition, if
recommended and authorised by the staff of Netcare 911: provided that the emergency occurs
within the borders of South Africa.
1.1.1.4 No benefits for emergency transport outside the borders of South Africa.
Necesse benefit option:
1.1.1.5 The transport of a beneficiary, being a resident of South Africa, to the nearest, most appropriate
facility equipped for the beneficiary’s non-life-threatening emergency medical condition, if
recommended and authorised by the staff of Netcare 911: provided that the emergency occurs
within the borders of South Africa.
1.1.1.6 No benefits for emergency transport outside the borders of South Africa.
1.1.2 Emergency transport of medicine and/or blood
1.1.2.1 In the event that blood and/or medicine required for the treatment of a beneficiary in a lifethreatening
emergency medical condition are not available locally, Netcare 911 shall transport
these items to the appropriate facility.
2. Procedure to be followed in order to qualify for benefits
2.1 In the event of an emergency medical condition the following measures shall be applicable:
2.1.1 Any beneficiary who requires emergency medical assistance must phone the Netcare 911
contact centre so that the nature of the medical assistance required can be determined and the
member can be transported to the nearest appropriate medical facility, if necessary.
2.1.2 Should the emergency medical condition be of such a nature that the member is not able to
contact the Netcare 911 contact centre or request emergency transport personally, the
dependant of the member, his spouse or other representative must notify the Netcare 911
contact centre within twenty-four (24) hours after an incident occurred.
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49.
2.1.3 In the event that the Netcare 911 contact centre is not notified of the incident as stipulated
above and the necessary approval is not granted, Netcare 911 reserves the right to refuse
payment to a third party in respect of the rendering of emergency services.
2.1.4 In the event of an incident that is not life-threatening (non-emergency) the member shall be
liable for payment of the account if the necessity for emergency medical transport has not been
confirmed by Netcare 911.
3. Services that do not qualify for benefits
3.1 Netcare 911 shall not be responsible for rendering any assistance to the beneficiary in
circumstances where the emergency medical condition –
3.1.1 is not reported to the Netcare 911 contact centre by the beneficiary or a representative on his
behalf unless the circumstances of the emergency medical condition dictate otherwise, in which
case authorisation must be obtained within twenty-four (24) hours after the incident;
3.1.2 is of such nature that, in the opinion of the medical staff appointed by Netcare 911, no medical
assistance and/or transport is justified;
3.1.3 occurs after the expiry of the beneficiary’s membership;
3.1.4 occurs in periods when the beneficiary’s benefits have been suspended; and
3.1.5 is related to the benefit exclusions as listed in paragraph 1.25 of Schedule C.
4. General stipulations
4.1 Neither Netcare 911 nor Medihelp shall be liable for the payment of interest owing as a result of
the non-payment of a claim that cannot be ascribed to Netcare 911 or Medihelp.
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50.
MEDIHELP RULES: SCHEDULE E
Procedure applicable during voting at a general meeting
1. Voting takes place for the period as determined by the chairman in consultation with the
meeting.
2. Voting on every item on the agenda that must be voted on shall take place by means of a vote
by ballot cast by those members who are present at the meeting as well as votes cast by proxy
by warrantors. A ballot paper shall only be issued to a person who is present at a meeting and
who can provide proof of membership of Medihelp and whose subscriptions are paid up.
3. The chairman, in consultation with the meeting, appoints a chief scrutineer and scrutineers
responsible for collecting ballot papers and counting votes.
4. The officials who issue ballot papers, shall record the number of ballot papers issued and shall
report this number to the chief scrutineer before voting commences.
5. Once the chief scrutineer has indicated to the chairman that all members who are entitled to
vote have received ballot papers, the chairman shall declare that ballot papers shall no longer
be issued, that no person who acts as a proxy shall legally represent any proxy vote if such
person is not present at that time, and that voting will commence:
5.1 A member/proxy places his ballot paper(s) on which he has indicated his choice(s) in a sealed
ballot box.
5.2 Persons who have elected not to cast a vote, are also required to place their ballot papers in the
sealed ballot box.
5.3 No ballot papers may be placed in the ballot box after expiry of the voting period, and the
meeting shall continue with proceedings.
6. The procedure regarding the counting of votes shall take place as follows:
6.1 The chief scrutineer opens the ballot box in the presence of all the scrutineers.
6.2 The chief scrutineer shall ascertain whether the number of ballot papers in the ballot box
corresponds with the number of ballot papers issued. Should the number of ballot papers in the
ballot box not correspond with the number of ballot papers issued, the election is invalid and
must be held again: provided that the general meeting may, by means of a majority of votes of
members who are present in person, condone the disparity in the number of ballot papers if
such disparity does not influence the results of the election.
6.3 Votes are counted and as soon as a result has been obtained, the chief scrutineer must hand a
certificate to the chairman which contains the following:
6.3.1 The number of ballot papers issued and that such number corresponds with that in the ballot
box.
6.3.2 The number of valid proxy votes.
6.3.3 In the case of the election of members of the Board of Trustees, the number of votes obtained
by each candidate, and in the case of all other matters voted on, the results of voting, including
the number of votes in favour of, against, abstained from and spoilt.
6.3.4 The number of spoilt votes and spoilt proxy votes.
6.3.5 A declaration that voting was conducted in accordance with the prescribed procedure.
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51.
MEDIHELP RULES: ANNEXURE 1
Personal Medical Savings Account
1. The monthly savings account contributions for the various benefit options are as set out in
Schedule A.
2. A credit facility, equalling the applicable monthly contribution to the personal medical savings
account multiplied by twelve (12), shall be made available to a member at the beginning of each
financial year. The credit facility shall be recalculated at the beginning of each month by
multiplying the applicable monthly contribution to the personal medical savings account by the
remaining number of months until the end of the financial year. Should a member be enrolled
during the course of a financial year, the credit facility will be prorated according to the
remaining number of months of the financial year.
3. The funds in the savings account, including the credit facility, shall be used to –
3.1 pay for medical expenses which are payable from the savings account, as contemplated in
Schedule B, and
3.2 pay expenses exceeding the applicable tariff, levies and member co-payments,
provided that all accounts to be paid from the savings accounts shall be submitted to Medihelp
within the prescribed submission period.
4. The funds in the personal medical savings account shall not be used to pay for the cost of
prescribed minimum benefits or any co-payment in respect thereof or to pay for subscriptions.
5. In the event of a member who –
5.1 interchanges to another medical scheme or transfers to another benefit option of Medihelp, the
funds in the savings account shall –
5.1.1 be transferred to the member’s personal medical savings account at the other medical scheme
or benefit option within four (4) calendar months after termination of membership of Medihelp; or
5.1.2 be refunded to the member within four (4) calendar months after termination of his membership
of Medihelp or after such transfer, subject to applicable laws, if the other scheme or option does
not provide for a personal medical savings account;
5.2 terminates his membership and is not admitted as a member of another medical scheme, the
funds in the savings account shall be refunded to the member within four (4) calendar months
after termination of membership of Medihelp, subject to applicable laws; or
5.3 dies, the funds in the savings account shall be transferred to the savings account of his
dependants who qualify for continued membership, and should he not have any such
dependants, the funds in the savings account shall be paid to his estate, subject to applicable
laws.
6. Notwithstanding the stipulations of paragraph 5, the funds in the savings account shall be used
to offset any debt owed by the member to Medihelp on termination of membership and a debit
balance shall be payable to Medihelp immediately.
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52.
MEDIHELP RULES: ANNEXURE 2
Prescribed Minimum Benefits
1. General
1.1 Subject to the stipulations of rule 8.1, benefits regarding a prescribed minimum benefit condition
shall be paid from the relevant benefit category as set out in Schedules B1 to B7, provided that
Medihelp shall grant benefits in terms of the conditions contemplated in this Annexure at 100%
of the cost, without limits or co-payments, in respect of the diagnosis, treatment and care costs
of –
1.1.1 the prescribed minimum benefit conditions as listed in Schedule A to the Regulations; and
1.1.2 an emergency medical condition.
1.2 In the case of chronic conditions regarding prescribed minimum benefits, benefits shall be
limited to the scope of the therapeutic algorithms as determined by the Medical Schemes Act
and chronic conditions in the treatment pairs of PMB.
2. Pre-registration
2.1. In order to qualify for prescribed minimum benefits, the prescribed minimum benefit condition as
well as each separate service relating to the condition must be pre-registered in the manner as
prescribed by Medihelp: provided that –
2.1.1 in the event of the diagnosis not being confirmed prior to the service rendering, the service must
be registered within forty-eight (48) hours after the service has been rendered, or on the first
working day thereafter should the registration period fall over a weekend or public holiday;
2.1.2 a psychiatric admission shall be regarded as a prescribed minimum benefit condition during the
pre-registration of the admission; and
2.1.3 in the case of an emergency medical condition, registration must take place on the subsequent
day of business after the incident.
2.2. Registration shall be subject to Medihelp’s protocols, including the applicable medicine
formularies, which apply to the treatment of the prescribed minimum benefit condition.
2.3 Should the prescribed minimum benefit condition as well as each separate service relating to
the condition not be registered with Medihelp in the manner set out in paragraph 2.1, benefits
shall be granted subject to the applicable tariffs/member co-payments/levies/annual limits and
other conditions as stipulated in Schedule B1 to B7.
3. Designated service provider
3.1 Where applicable, the prescribed minimum benefit services and/or prescribed medicine must be
obtained from a designated service provider. Details of the designated service providers, which
include all Government hospitals, are available from Medihelp.
3.2 If a beneficiary voluntarily obtains services and/or prescription medicine from a non-designated
service provider, the co-payments as set out in paragraph 7.1 shall apply.
3.3 If a beneficiary involuntarily obtains services and/or prescription medicine from a nondesignated
service provider, the stipulations of paragraph 7.1 shall not apply if –
3.3.1 the service was not available from the designated service provider or would not be provided
without unreasonable delay;
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3.3.2 immediate medical or surgical treatment for a prescribed minimum benefit condition was
required under circumstances or at locations which reasonably precluded the beneficiary from
obtaining such treatment from a designated service provider; or
3.3.3 there was no designated service provider within reasonable proximity to the beneficiary’s
ordinary place of business or personal residence.
3.4 Except in the case of an emergency medical condition, pre-authorisation must be obtained from
Medihelp if the member involuntarily obtains the services from a provider other than a
designated service provider in terms of paragraph 7.1, to enable Medihelp to confirm that the
circumstances as contemplated are applicable.
4. Medicine
4.1 If medicine is dispensed and the beneficiary opts to use medicine which costs more than the
applicable Medihelp Reference Price, the member will be liable to pay the difference between
the cost of the medicine dispensed and the reference price used to determine the benefit
amount.
4.2 The stipulations of paragraph 4.1 shall not apply in cases where a beneficiary has to use
medicine which costs more than the Medihelp Reference Price for clinically appropriate
reasons, as motivated by the member’s attending physician, provided that pre-authorisation is
obtained from Medihelp.
5. Diagnostic services for unconfirmed prescribed minimum benefit conditions
5.1 Where diagnostic tests do not result in confirmation of a prescribed minimum benefit condition,
except for an emergency medical condition, such diagnostic tests shall not be considered as
prescribed minimum benefits.
6. Protocols
6.1 If a beneficiary voluntarily obtains services and/or prescription medicine which deviates from the
applicable protocols, the co-payments as set out in paragraph 7.2 shall apply.
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7. Applicable co-payments
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