{"id":750,"date":"2010-05-19T20:19:45","date_gmt":"2010-05-19T20:19:45","guid":{"rendered":"http:\/\/profconsure.co.za\/?page_id=750"},"modified":"2019-11-23T10:19:23","modified_gmt":"2019-11-23T08:19:23","slug":"scheme-rules","status":"publish","type":"page","link":"https:\/\/profconsure.co.za\/?page_id=750","title":{"rendered":"Scheme Rules"},"content":{"rendered":"

\"\"<\/a><\/p>\n

Rules as registered by the Registrar \u2013 Version 4.2010
\n1.
\nRULES OF MEDIHELP
\n(As registered in English)
\n1. Name of the Medical Scheme
\nThe name of the medical scheme is \u201cMedihelp\u201d.
\n2. Legal Persona
\nMedihelp 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
\nthe Medical Schemes Act, 1998 (Act No 131 of 1998), the Regulations issued in terms thereof and
\nthese Rules.
\n3. Registered Office
\nThe 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.
\n4. Objectives
\nThe objectives of Medihelp are to undertake liability in return for a subscription to \u2013
\n4.1 establish and maintain a fund from subscriptions payable by members and other
\ncontributions received from any other source, to, subject to the conditions and basis as
\ncontained in the Rules, grant financial assistance to members and\/or their registered
\ndependants in respect of the obtaining of an applicable healthcare service, as stated in
\nSchedule B; and
\n4.2 render an applicable healthcare service as stated in Schedule B or any other related
\nservice to members and\/or their registered dependants, either by Medihelp itself or by
\nany supplier of a service or group of suppliers of a service in association with or in terms
\nof an agreement with Medihelp.
\n5. Definitions
\nIn these Rules, words defined in the Medical Schemes Act, 1998 (Act No 131 of 1998) have the
\nsame meaning as those assigned to them in the said Act and, unless inconsistent with the context, all
\nwords and expressions denoting the masculine gender shall include the feminine, words denoting the
\nsingular number shall include the plural and vice versa, and the following expressions shall have the
\nmeaning hereby assigned to them \u2013
\n\u201cAct\u201d means the Medical Schemes Act, 1998 (Act No 131 of 1998) and any regulations
\nissued in terms of the provisions of the said Act.
\n\u201cAll-inclusive nursing service\u201d means a service rendered by a professional, registered
\nperson as alternative to hospitalisation, as authorised beforehand by the Principal Officer
\nat the hand of managed healthcare programmes.
\n\u201cAnnexure\u201d means an annexure to the Rules that is considered part of the Rules.
\n\u201cApplicant\u201d means a person who applies for membership for himself and registration of
\nhis dependants, if any.
\n\u201cApplication\u201d means an application, in a manner approved by the Board of Trustees, for
\nmembership or for the registration of a dependant.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n2.
\n\u201cAuditor\u201d means an auditor who is registered in terms of the Public Accountants\u2019 and
\nAuditors\u2019 Act, 1991 (Act No 80 of 1991).
\n\u201cBed day\u201d means, with regard to admission in a hospital, unattached operating theatre
\nunit, clinic of a local authority or registered step-down facility, each day or portion thereof
\nthat a person is admitted to the facility.
\n\u201cBeneficiary\u201d means a member or a person registered as a dependant of a member.
\n\u201cBenefits\u201d means the benefits of Medihelp as stipulated in rule 14 and Schedule B.
\n\u201cBoard of Trustees\u201d means the Board of Trustees as contemplated in section 29(1)(a)
\nof the Act read with rule 17.
\n\u201cBroker\u201d means a person whose business, or part thereof, entails providing a service or
\nadvice in respect of the introduction of prospective members to Medihelp, and who has
\nbeen accredited as a broker by the Council for Medical Schemes and who has been
\ncontracted with Medihelp for rendering such services.
\n\u201cCalendar month\u201d means a period extending from the first day to the last day of any
\none of the twelve (12) months of the year.
\n\u201cChronic medication management programme\u201d means a pre-authorisation
\nprogramme, in terms of which prescribed medicine is authorised according to clinical
\nprotocols and formularies in order to register members on the management programme
\nfor the medical treatment of chronic diseases.
\n\u201cClaim\u201d means a benefit amount to which a member is entitled according to the Rules in
\nrespect of expenditure incurred by him or his dependants in connection with a relevant
\nhealth service.
\n\u201cCondition-specific waiting period\u201d means a period during which a beneficiary is not
\nentitled to claim benefits in respect of a condition for which medical advice, diagnosis,
\ncare or treatment was recommended or received within the 12-month period ending on
\nthe date on which an application for membership was made.
\n\u201cCredit facility\u201d means, with regard to the personal medical savings account of a
\nmember of a benefit option, a credit amount available to the member for the payment of
\nday-to-day expenses.
\n\u201cDate of application\u201d means the date on which an application for membership and\/or
\nan application for the registration of a dependant is received at the offices of Medihelp.
\n\u201cDate of service\u201d means \u2013
\n(a) in the case of a consultation, visit or treatment by a medical practitioner, a
\ndentist or person providing supplementary health services, the date on which
\neach consultation, visit or treatment took place, whether it was for the same
\nillness or not;
\n(b) in the case of an operation, procedure or confinement the date on which the
\noperation, procedure or confinement took place;
\n(c) in the case of hospitalisation, the date of each discharge from hospital, nursing
\nor maternity home or the date of termination of membership, whichever occurs
\nfirst;
\n(d) in the case of any other service or medical appliance, the date on which the
\nservice was rendered or the medical appliance received; and
\nRules as registered by the Registrar \u2013 Version 4.2010
\n3.
\n(e) in the case of an accident or event referred to in rule 15.4, the date of final
\nsettlement and\/or court order.
\n\u201cDependant of a member\u201d means the spouse or partner as well as the dependent
\nchildren, father, mother, brothers, sisters and grandchildren of the member and such
\nother person as acknowledged as a dependant in the exclusive discretion of the Board of
\nTrustees in respect of whom the member is liable for family care and support, and who is
\nnot a member or a dependant of a member of another medical scheme. For the purpose
\nof applying this definition, the following shall mean:
\n(a) \u201cDependent child\u201d means a child who is not self-supporting and in respect of
\nwhom the member is liable for family care and support. For the purpose of
\napplying this definition, child means \u2013
\n(a)(i) the natural child of a member; or
\n(a)(ii) a stepchild; or
\n(a)(iii) an adopted child or a child in the process of being adopted and who has been
\nplaced in the custody of the member, as defined in section 1 of the Child Care
\nAct, 1983 (Act No 74 of 1983); or
\n(a)(iv) a foster child or a child in the process of being placed in foster care and who
\nhas been placed in the custody of the member, as defined in the Child Care
\nAct, 1983 (Act No 74 of 1983); or
\n(a)(v) a child, as defined in (i) to (iv) above, of a member\u2019s partner.
\n(b) \u201cFamily care and support\u201d, means, with regard to the dependant of a
\nmember, the financial care by a member of a dependant who is not selfsupporting.
\n(c) \u201cPartner\u201d means a person of the same or opposite gender within a relationship
\nof a dedicated and permanent nature with the member that is comparable to a
\nmarriage based on objective criteria of mutual dependence, and who shares a
\ncommon household with the member.
\n(d) \u201cSpouse\u201d means a person of the opposite gender within a marriage
\nsolemnised in accordance with any Act or custom.
\n\u201cDesignated service provider\u201d means a healthcare provider or group of providers
\nappointed by Medihelp as preferred provider(s) to provide services to the members in
\nrelation to one or more prescribed minimum benefit condition(s), which may include the
\ndiagnosis and\/or treatment and\/or care as required by the Regulations issued in terms of
\nthe Act.
\n\u201cDiscretionary medicine\u201d means medicine administered in the consulting rooms for a
\nspecific diagnosis, which medicine must be pre-authorised by the Principal Officer.
\n\u201cEmergency medical condition\u201d means any sudden and unexpected onset of a health
\ncondition that requires immediate medical or surgical treatment, where failure to provide
\nsuch treatment would result in serious impairment to bodily functions or serious
\ndysfunction of a bodily organ or part, or would place the person\u2019s life in serious jeopardy:
\nprovided that the condition is certified as such by a medical practitioner.
\n\u201cFamily\u201d means the member and all his registered dependants.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n4.
\n\u201cGeneral care\u201d means a service, irrespective of the point of such service, which is
\nexcluded from benefits and which can be rendered by a registered professional person
\nor any other person in respect of a beneficiary, and which includes assistance with
\npersonal hygiene (bathing, dressing, changing incontinence diapers and similar
\nassistance), catheter care, oral or tube feeding (excluding the placement of catheters
\nand tubes), administering and\/or supervision of oral, rectal, vaginal or topical medicine,
\nassistance with mobilisation and comfort care to prevent bedsores.
\n\u201cGeneral waiting period\u201d means a period in which a beneficiary is not entitled to claim
\nany benefits.
\n\u201cLate joiner\u201d means a person, excluding a dependent child, who is thirty five (35) years
\nof age or older and who applies for membership as a beneficiary, and \u2013
\n(a) who was not at any time registered as a beneficiary with one or more medical
\nscheme(s) prior to 1 April 2001; or
\n(b) was registered as a beneficiary with one or more medical scheme(s) prior to
\n1 April 2001, but with a continuous interruption in coverage of more than three
\n(3) months since 1 April 2001.
\n\u201cLength of stay parameters\u201d means the agreed upon length of stay in a contracted
\nhospital\/facility.
\n\u201cLife-threatening acute infections\u201d means all life-threatening infections requiring
\nhospitalisation. Medihelp reserves the right to require proof of the severity of the infection
\nin whatever form.
\n\u201cManaged healthcare programmes\u201d means clinical and financial risk assessment and
\nmanagement of healthcare, to facilitate appropriateness and cost-effectiveness of
\nrelevant health services within the constraints of what is affordable. This is accomplished
\nby means of a set of formal techniques, as approved by the Board of Trustees, that are
\ndesigned to monitor the use of, and evaluate the clinical necessity, appropriateness,
\nefficacy, and efficiency of healthcare services, procedures and the appropriateness of
\nthe point of service, on the basis of which appropriate managed healthcare interventions
\nare made.
\n\u201cMedicine\u201d means a substance or mixture of substances used or purporting to be
\nsuitable for use or manufactured or sold for use in \u2013
\n(a) the diagnosis, treatment, mitigation, modification or prevention of disease,
\nabnormal physical or mental state or the symptoms thereof; or
\n(b) restoring, correcting or modifying any somatic or psychic function.
\n\u201cMedihelp\u201d means the medical scheme as a legal persona which comprises the
\nmembers, the Board of Trustees and the Principal Officer and his staff, as it is indicated
\nin the Rules respectively.
\n\u201cMember\u201d means someone who is registered or admitted as a member of Medihelp or
\nwho is a member in terms of the Rules.
\n\u201cMonth\u201d means a period extending from a day in one month to the day preceding the
\nday corresponding numerically to that day in the following month.
\n\u201cMonthly income\u201d means the member\u2019s gross monthly remuneration before any
\ndeductions.
\n\u201cParticipating employer\u201d means an employer who has contracted with Medihelp for the
\npurposes of admission of its employees as members of Medihelp.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n5.
\n\u201cPersonal medical savings account\u201d means an account which is kept by Medihelp on
\nbehalf of a member of a benefit option, which is credited monthly with the member\u2019s
\ncontribution as set out in Schedule A, and which is used to pay medical expenses as set
\nout in Schedule B.
\n\u201cPre-existing medical condition\u201d means a condition for which medical advice,
\ndiagnosis, care or treatment was recommended or received within the 12-month-period
\npreceding the date on which application for membership is made.
\n\u201cPrescribed minimum benefit condition\u201d means a condition contemplated in
\nAnnexure A of the Regulations and any emergency medical condition.
\n\u201cPrescribed minimum benefits\u201d means the benefits contemplated in section 29(1)(o)
\nof the Act and consist of the provision of the diagnosis, treatment and care costs of \u2013
\n(a) the diagnosis and treatment pairs listed in Annexure A of the Regulations,
\nsubject to any limitations specified therein; and
\n(b) any emergency medical condition,
\nprovided that benefits will be allocated from the effective date of the preauthorisation\/
\npre-registration.
\n\u201cPrincipal Officer\u201d means the principal officer appointed in terms of section 57(4)(a) of
\nthe Act.
\n\u201cProcedure\u201d means any act or action, either surgical or non-surgical in nature,
\nperformed by a service provider(s) in the diagnosis and treatment of a medical condition,
\nand includes all direct and indirect services relating to the particular service(s), including
\nhospitalisation, irrespective of where the act or action is performed.
\n\u201cProtocol\u201d means a set of clinical guidelines in relation to the optimal sequence of
\ndiagnostic testing and treatments for specific conditions and includes, but is not limited
\nto, clinical practice guidelines, standard treatment guidelines, disease management
\nguidelines, treatment algorithms and clinical pathways.
\n\u201cRegistrar\u201d means the Registrar or Deputy Registrar(s) of Medical Schemes appointed
\nin terms of section 18 of the Act.
\n\u201cRules\u201d means the Rules of Medihelp as well as \u2013
\n(a) the provisions of the Act, charter, deed of settlement, memorandum of
\nassociation or other document by which Medihelp is constituted;
\n(b) the articles of association or other rules for the conduct of the business of
\nMedihelp; and
\n(c) the provisions relating to the benefits which may be granted by and the
\ncontributions which may become payable to Medihelp.
\n\u201cSchedule\u201d means a schedule to these Rules which shall be regarded as part of these
\nRules.
\n\u201cService\u201d means a relevant health service as defined in the Act.
\n\u201cSouthern Africa\u201d means the Republic of South Africa, Botswana, Lesotho, Malawi,
\nMozambique, Namibia, Swaziland and Zimbabwe.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n6.
\n\u201cSubscription\u201d means the amount which in terms of rule 13 is applicable to a particular
\nmember and payable monthly to Medihelp.
\n\u201cSupplier of service\u201d means a practitioner, person, organisation or an institution which
\nis authorised in terms of an act to render a relevant health service as defined in the Act.
\n\u201cTariff\u201d means the amount on which the benefits of Medihelp shall be calculated, and
\nthe following terms shall have the meanings as shown:
\n(a) \u201cCost\u201d is the net amount payable in respect of a relevant health service;
\n(b) \u201cGuideline tariff\u201d is the tariff for services which is calculated using the
\nNational Health Reference Price List for 2009 as basis plus 8%, and in the case
\nof medical, surgical and orthopaedic appliances and material for which a
\nNAPPI (National Pharmaceutical Product Interface) code has been allocated by
\nthe NAPPI Advisory Board (NAB), the applicable price linked to the NAPPI
\ncode;
\n(c) \u201cMedicine price\u201d is the single exit price plus the applicable professional fee,
\nwhere applicable, as published from time to time in terms of the Medicines and
\nRelated Substances Control Act, 1965 (Act No 101 of 1965) as amended;
\n(d) \u201cMedihelp Dental Tariff\u201d means the benefits for dentistry in accordance with
\nthe dental schedule of the Scheme as agreed between Medihelp and its
\ncontracted dental managed healthcare organisation;
\n(e) “Medihelp Optometry Tariff” means the benefits for optometry in accordance
\nwith the optometry schedule of the Scheme as agreed between Medihelp and
\nits contracted optometry managed healthcare organisation;
\n(f) \u201cMedihelp Reference Price\u201d is the maximum amount on which benefits for
\nmedicine prescribed for the treatment of a chronic sickness condition which is
\nregistered with Medihelp as a prescribed minimum benefit condition are
\ncalculated;
\n(g) \u201cMMAP\u201d (Maximum Medical Aid Price) is the maximum amount on which
\nbenefits for chronic and non-chronic medicine are calculated, excluding
\nmedicine prescribed for the treatment of a prescribed minimum benefit
\ncondition which is registered as such with Medihelp;
\n(h) \u201cScheme tariff\u201d is the tariff as approved by the Board of Trustees and is
\ncontractually agreed with a service provider or a group of service providers,
\nwhich includes, but is not limited to, per diem, fixed and global fees; and
\n(i) \u201cUPFS\u201d (Uniform Patient Fee Schedule) is the tariff issued by the Department
\nof Health, which is applicable to public hospitals.
\n“To-take-out medicine (TTO)” means medicine to take out at the time of discharge from
\na hospital or day clinic, which medicine directly pertains to the reason for the admission
\nto the hospital or day clinic and which is dispensed and charged by the hospital or day
\nclinic on prescription of the attending physician.
\n6. Membership
\nAdmission
\n6.1 Any person or group of persons may be admitted as members in terms of the Rules of
\nMedihelp.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n7.
\nApplication for membership
\n6.2 An applicant must apply for membership by means of an application form as required by
\nMedihelp and must provide such additional information as Medihelp may require and is
\npersonally responsible for any expenditure incurred in this regard, except in the case of
\nmedical reports requested by Medihelp.
\n6.3 A minor as contemplated in section 30(1)(f) of the Act may apply for membership of
\nMedihelp with the assistance of his parent or guardian.
\nDate of enrolment as a member
\n6.4 The applicant will be enrolled as a member from the date requested on the application,
\nprovided that the application is received by Medihelp before the date on which
\nmembership is requested, otherwise enrolment will commence from the date on which
\nthe application is received.
\n6.5 In the case where Medihelp has an agreement with the applicant\u2019s employer, the
\napplicant will be enrolled as a member from the date as agreed on with the employer.
\nConditions for enrolment as a member
\n6.6 No person is enrolled as a member of Medihelp while such person is a member of
\nanother medical scheme.
\n6.7 An applicant will be enrolled as a member subject to a waiting period as contemplated in
\nrule 8 and\/or late-joiner penalty as may be applicable to an applicant and\/or his
\ndependants in terms of the Rules.
\nContinued membership
\n6.8 A member may retain his membership together with his dependants in the event of his
\nretiring from the service of his employer or his employment being terminated by his
\nemployer on account of age, ill health or other disability: provided that he shall be
\npersonally responsible to pay the applicable subscription per debit order to Medihelp.
\n7. Registration, Deregistration and Continued Membership of Dependants
\nApplication for the registration of dependants
\n7.1 A member may register all his dependants with Medihelp who qualify in terms of the
\nRules, subject to such waiting periods and\/or late-joiner penalties as may apply for the
\ndependant in terms of the Rules.
\n7.2 A person may not be registered as a dependant of more than one member of Medihelp
\nor as a dependant of a member of Medihelp and a member of another medical scheme
\nsimultaneously.
\n7.3 A dependant as contemplated in the definitions may not be enrolled as a dependant of a
\nmember in another benefit option than the benefit option of the member.
\n7.4 Application must be made on an application form required by Medihelp and Medihelp
\nmay require that any application for the registration of a dependant must be
\naccompanied by the relevant marriage or birth certificate, adoption order, foster care
\norder or any other applicable certificate or document which Medihelp may require.
\nDate of registration of dependants
\n7.5 A dependant shall be registered \u2013
\nRules as registered by the Registrar \u2013 Version 4.2010
\n8.
\n7.5.1 from the date on which the application is received or a later date as requested on the
\napplication; or
\n7.5.2 in the case of a marriage, birth, adoption or where a child is placed in the member\u2019s
\nfoster care, from the date of such occurrence: provided that the application for
\nregistration must be submitted to Medihelp not later than ninety (90) days after the above
\ndate(s): further provided that should the member fail to comply with this stipulation, the
\ndependant will be registered from the date on which the application is received, subject
\nto rule 8.5 and such waiting period and\/or late-joiner penalties as determined by the
\nRules.
\nDeregistration of dependants
\n7.6 Medihelp must be advised within one (1) month from the date on which a dependant no
\nlonger qualifies to be registered: provided that \u2013
\n7.6.1 should the member fail to comply with this notice period, such deregistration may be
\nimplemented at the earliest from the beginning of the calendar month in which the
\nnotification is received; and
\n7.6.2 in the case of employer groups, deregistration will be implemented from the date as
\nadvised by the employer.
\nContinued membership of dependants
\n7.7 The registered dependant of a deceased member shall be entitled to continuous
\nmembership without the imposition of new waiting periods and\/or late-joiner penalties,
\nuntil such dependant becomes a member or a dependant of a member of another
\nmedical scheme, and is personally responsible to pay the applicable subscription per
\ndebit order to Medihelp: provided that the dependant accepts membership not later than
\nninety (90) days from the date on which Medihelp informed such dependant that he
\nqualifies for continued membership.
\n8. Application of Waiting Periods
\n8.1 If a person was not a beneficiary of a medical scheme for a period of ninety (90) days or
\nmore preceding the date of enrolment at Medihelp the following waiting periods may be
\nimposed, which waiting periods shall also apply to the prescribed minimum benefits:
\n8.1.1 A general waiting period of up to three (3) months.
\n8.1.2 A condition-specific waiting period of up to twelve (12) months.
\n8.2 If a person was a beneficiary of a previous medical scheme or schemes for a continuous
\nperiod of up to twenty-four (24) months, terminating less than ninety (90) days
\nimmediately prior to the date of enrolment at Medihelp, the following waiting periods may
\nbe imposed:
\n8.2.1 A condition-specific waiting period of up to twelve (12) months, except in respect of a
\nprescribed minimum benefit condition.
\n8.2.2 Where the previous medical scheme had imposed a general or condition-specific waiting
\nperiod, and such waiting period had not expired at the time of termination of
\nmembership, the unexpired duration of such waiting period may be imposed by
\nMedihelp.
\n8.3 Medihelp may impose a general waiting period of up to three (3) months, except in
\nrespect of a prescribed minimum benefit condition, upon any person who was previously
\na beneficiary of a medical scheme or schemes for a continuous period of more than
\ntwenty-four (24) months, terminating less than ninety (90) days immediately prior to the
\ndate of enrolment at Medihelp.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n9.
\n8.4 No waiting period shall be imposed upon a beneficiary who changes from one benefit
\noption to another: provided that any remaining period of existing waiting periods may be
\napplied.
\n8.5 A waiting period shall not be imposed on the child of a member born during the period of
\nmembership.
\n8.6 In the following cases Medihelp shall not impose a general or condition-specific waiting
\nperiod upon a person in respect of whom an application is made for membership or
\nadmission as a dependant if such person was previously a beneficiary of a medical
\nscheme, terminating less than ninety (90) days immediately prior to the date of enrolment
\nat Medihelp: provided that Medihelp may apply any remaining period of existing general
\nand condition-specific waiting periods applied by the previous medical scheme:
\n8.6.1 where the termination of membership of the previous scheme is required as a result of
\nchange of employment; and
\n8.6.2 where an employer changes or terminates the medical scheme of its employees and
\nenrols them at Medihelp, provided that such termination shall occur at the beginning of
\nMedihelp\u2019s financial year, or that notice is received from the employer on or before
\n30 September of the preceding financial year that such transfer shall occur at the
\nbeginning of the next financial year.
\n8.7 Should the lapse in membership referred to in rule 8.6 be ninety (90) days or longer, a
\ngeneral waiting period of up to three (3) months and a condition-specific waiting period of
\nup to twelve (12) months may be imposed.
\n8.8 If the members of a medical scheme who are members of that medical scheme by virtue
\nof their employment by a particular employer terminate their membership of the said
\nmedical scheme with the object of obtaining membership of Medihelp, Medihelp shall
\nadmit to membership, without a waiting period or the imposition of new restrictions on
\naccount of the state of those members\u2019 health or the health of any of their dependants,
\nany member or a dependant of such a medical scheme who –
\n8.8.1 enjoy continued membership of such a scheme; or
\n8.8.2 enjoy continued membership of such a scheme as the dependant of a deceased member
\nof such a scheme.
\n9. General Stipulations Applicable to Waiting Periods
\nRequesting medical reports
\n9.1 Medihelp may require that a medical report be provided in respect of any pre-existing
\nmedical condition before a beneficiary is enrolled, and the cost of such medical report
\nshall be paid for by Medihelp: provided that \u2013
\n9.1.1 Medihelp may designate a service provider to provide such medical report; and
\n9.1.2 should the applicant make use of a service provider other than the service provider
\ndesignated by Medihelp, the applicant shall be responsible for payment of the cost of
\nsuch examination.
\n9.2 In cases where Medihelp is responsible for payment of an account, the applicant must
\nsubmit a specified account to Medihelp.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n10.
\n10. General Stipulations with regard to Membership
\nProof of membership
\n10.1 Proof of membership, on which shall be indicated such details as prescribed by the Act,
\nshall be issued to every member on enrolment and with each change in membership
\ndetails.
\nMembership card
\n10.2 A membership card shall be issued to every member on enrolment and with each
\nchange in beneficiary details and\/or change in benefit option. This card, which remains
\nthe property of Medihelp, must be produced on request to a supplier of service and must
\nbe returned to Medihelp on termination of membership.
\n10.3 The utilisation of a membership card by any person other than the member and\/or his
\nregistered dependants, with the knowledge or consent of the member and\/or his
\nregistered dependants is not permitted and shall be construed as a fraudulent act.
\nCertificate of membership
\n10.4 Medihelp shall, on the termination of membership, deregistration of a dependant or on
\nrequest of a member, furnish a certificate of membership to such person within one (1)
\nmonth from the date of the termination of membership or the request.
\nChange of address
\n10.5 Medihelp must be advised within one (1) month of any change of address: provided that
\nsuch address shall be within the borders of the RSA. Medihelp shall accept no liability or
\nresponsibility in the event of a member being prejudiced on account of his failure to
\ncomply with this rule.
\nApplicability of the Rules
\n10.6 A detailed summary of the Rules containing the member\u2019s rights and responsibilities
\nshall be sent free of charge to a member on enrolment.
\n10.7 The Rules shall be binding on every beneficiary and approval by Medihelp of the
\nmember\u2019s application for membership and\/or registration of a dependant shall be
\nregarded as the unqualified undertaking of the beneficiaries to abide by the Rules and
\nany amendment thereto.
\nBanking details
\n10.8 A member must furnish Medihelp with the relevant banking details at such recognised
\nfinancial institution in the RSA for the recovery of subscription and with any changes to
\nsuch details, and Medihelp shall accept no responsibility\/liability for any debit order
\nrecovery made in error due to erroneous information furnished to Medihelp or outdated
\ninformation in the possession of Medihelp.
\n11. Termination of Membership
\n11.1 A member whose membership has been terminated shall, from the date of such
\ntermination, have no further claims against Medihelp or the assets of Medihelp except in
\nrespect of accounts for services rendered before the date on which the termination of
\nmembership became effective and provided that a claim was submitted in accordance
\nwith rule 15.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n11.
\nResignation of a member who is an employee of a participating employer
\n11.2 No person for whom membership of Medihelp is a condition of service in terms of an
\nagreement between Medihelp and an employer may, while he remains in service, resign
\nwithout the consent of his employer or be deprived of his membership by Medihelp
\nwithout prior notification to his employer.
\n11.3 An employer\u2019s participation in Medihelp shall be terminated in accordance with the notice
\nperiod as determined in the agreement between Medihelp and the employer.
\nVoluntary termination by a member who is not part of a participating employer
\n11.4 Voluntary termination of membership by a member must be done in advance in writing
\nand such date of termination shall not be a date prior to the date on which Medihelp
\nreceived the request, while any claim to benefits shall terminate after the last day of
\nmembership.
\nDeath of the member
\n11.5 The membership of a deceased member shall terminate on the day following the date of
\ndeath.
\nFailure to pay amounts due to Medihelp
\n11.6 If a member fails to pay subscription and\/or any other amount due to Medihelp on the
\ndate on which it became due, Medihelp shall notify such member and participating
\nemployer thereof and inform the member and\/or participating employer that if it is not
\nsettled on the date indicated in the letter, benefits shall be suspended in respect of
\nclaims which arose during the period of default and that membership may be terminated
\nif the arrears subscription and\/or amount due is not remitted within thirty (30) days from
\nthe date of suspension: provided that the Principal Officer may, in his exclusive
\ndiscretion, determine the period in which the arrears subscription and\/or other amount
\ndue may be remitted and interest may be charged at the prime rate of Medihelp\u2019s
\nbankers.
\nAbuse of rights, falsified claims, misrepresentation and non-disclosure of material information
\n11.7 Medihelp may suspend the benefits of a beneficiary and\/or terminate his membership if
\nhe \u2013
\n11.7.1 submitted a fraudulent claim;
\n11.7.2 committed a fraudulent act; or
\n11.7.3 failed to disclose material information on the request of Medihelp.
\n11.8 Should it be determined, after a member has been accepted, that he has in any
\napplication supplied false information or withheld material information, the membership of
\nsuch a member may in the discretion of Medihelp, subject to the provisions of rule 11.2,
\nbe terminated and any amount paid as benefits by Medihelp shall be refunded.
\n12. Special Categories of Members
\nCertain civil pensioners
\n12.1 Medihelp renders a medical scheme service on behalf of the State for \u2013
\n12.1.1 certain civil pensioners who are exempt from the payment of subscription; and
\n12.1.2 members who obtained membership of Medihelp at the time of the dissolving of the
\nformer Development Boards.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n12.
\n13. Subscription
\n13.1 The member shall be responsible for payment of the full applicable subscription, and
\nirrespective of whether any waiting period is imposed on a beneficiary, the prescribed
\nsubscription, as indicated in Schedule A, shall be due on the first day of enrolment and
\nthereafter on the first day of each subsequent calendar month, although it shall be
\npayable retroactively at the end of each calendar month in which a person is enrolled as
\na beneficiary, and shall be paid not later than the first working day following the end of
\neach calendar month: provided that \u2013
\n13.1.1 the subscription may be paid partially or in full by the member\u2019s employer or former
\nemployer to Medihelp, in which case it is done in his capacity as the authorised agent of
\nthe member; and
\n13.1.2 a member who is personally responsible to pay the subscription in full or partially, must
\npay it by means of a debit order, in which case the member\u2019s banker shall act as his
\nauthorised agent in the payment thereof: provided that Medihelp may, in its sole
\ndiscretion, after receiving an application from the member, approve that the subscription
\nmay be paid by a means other than by debit order; and
\n13.1.3 in those cases where subscription is paid by the member\u2019s employer\/previous employer
\nit must be paid not later than the last working day following the month in which it
\nbecomes payable.
\n13.2 At a change in dependants, subscription shall \u2013
\n13.2.1 increase from the first day of the calendar month in which a person is registered as a
\ndependant, excluding newborns registered from the date of birth, in which case
\nsubscription shall increase from the beginning of the calendar month following the month
\nof registration; and
\n13.2.2 decrease from the first day of the calendar month following the calendar month in which
\na person\u2019s registration as a dependant is cancelled.
\n13.3 The subscription of a dependent child shall increase to that of a dependant other than a
\ndependent child, from the beginning of the calendar month in which the dependent child
\nreaches the age as applicable for the particular benefit option contained in Schedule A to
\nthe Rules.
\n13.4 No refund of any assets of Medihelp or any portion of a contribution, excluding the
\ncontributions by a member to a personal medical savings account, shall be paid to any
\nperson where such member\u2019s membership or registration of any dependant terminates
\nduring the course of a month.
\n13.5 The balance standing to the credit of a member in terms of a personal medical savings
\naccount shall at all times remain the property of the member.
\n13.6 In the case of uninterrupted continued membership of dependants after the death of a
\nprincipal member, the subscription of such re-registered dependants shall only be
\npayable from the beginning of the calendar month following the calendar month of the
\nprincipal member\u2019s death.
\n14. Benefits
\n14.1 On enrolment, an applicant has to choose to participate in one of the benefit options as
\ncontemplated in Schedule B and he together with his dependants shall be entitled to the
\nbenefits offered by that benefit option during a financial year.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n13.
\n14.2 Medihelp, or its contracted managed healthcare organisation, shall pay any benefit due
\nto a member on the grounds of a valid claim, either to the member or to the supplier of
\nservice, within thirty (30) days after receipt of the claim.
\n14.3 Subject to the provisions of rule 8.1, benefit options shall offer 100% cover of the cost of
\nthe prescribed minimum benefits, without any member levies, member contributions or
\nlimits, provided that the conditions contemplated in Schedule B and Annexure 2 are met.
\n14.4 In relation to a service rendered outside Southern Africa \u2013
\n14.4.1 benefits shall only be granted on medical services rendered during the first ninety (90)
\ndays as from the date of departure to treat an emergency medical condition: provided
\nthat a beneficiary who is working or studying outside Southern Africa on instruction of his
\nemployer shall not be subject to this limitation;
\n14.4.2 benefits shall be calculated according to the applicable tariff of a similar service rendered
\nin the Republic of South Africa; and
\n14.4.3 the claim must be submitted with the documentation as may be required by Medihelp or
\nits contracted managed healthcare organisation.
\n14.5 Medihelp or its contracted managed healthcare organisation may, on such conditions as
\nit may determine, make such contribution as would be the normal contribution of
\nMedihelp in respect of a claim arising from an accident or events for which a member or
\na dependant has received or is likely to receive compensation from any source
\nwhatsoever, including travel insurance: provided that the member must cede any claim
\nfor medical expenses against a third party to Medihelp or its contracted managed
\nhealthcare organisation.
\n14.6 Except in the case of an emergency medical condition \u2013
\n14.6.1 Medihelp or its contracted managed healthcare organisation may require preauthorisation\/
\nregistration before a relevant health service is rendered: provided that
\nbenefits may be forfeited or a member contribution contemplated in Schedule B and
\nAnnexure 2 may be required should a member fail to obtain preauthorisation\/
\nregistration;
\n14.6.2 Medihelp may limit a beneficiary to make use of the services of only one selected
\ncontracted supplier of services per discipline should the beneficiary qualify for
\nparticipation in a managed healthcare programme;
\n14.6.3 Medihelp may prohibit a beneficiary qualifying for participation in a managed healthcare
\nprogramme from submitting claims to the Scheme should a contractual agreement for
\nthe direct submission and payment of scheme benefits exist between the Scheme and
\nthe contracted supplier; and
\n14.6.4 Medihelp may in cases where a clinical opinion has been obtained by the Scheme that
\nthe beneficiary does not utilise a medicine item(s) appropriately, decline authorisation for
\nsuch item(s) and not bear the financial responsibility with regard to such medicine items
\nobtained from the non-chronic medicine benefit, or hospitalisation\/treatment necessitated
\nas a result of the inappropriate utilisation of such medicine.
\n14.7 The benefit exclusions in Schedule C shall be applicable to all benefit options, except in
\nthe case of prescribed minimum benefits.
\n14.8 A beneficiary must apply to be registered on the chronic medication management
\nprogramme and an application shall only be considered if \u2013
\nRules as registered by the Registrar \u2013 Version 4.2010
\n14.
\n14.8.1 the illness is of a chronic nature;
\n14.8.2 the illness will continue indefinitely in its present state;
\n14.8.3 regular and continuous medicinal treatment is required; and
\n14.8.4 the medicine which is prescribed is considered by Medihelp to be life-saving and lifesustaining.
\n14.9 A person who is not a beneficiary of Medihelp may not claim or receive benefits from
\nMedihelp or its contracted managed healthcare organisation.
\n14.10 The allocation of benefits shall be subject to the applicable managed healthcare
\nprogrammes as approved by the Board of Trustees, where applicable, which includes
\nobtaining a second opinion by a relevant specialist on request of Medihelp.
\nProhibition on cession and attachment of benefits
\n14.11 No benefit or right in respect of a benefit payable under these Rules may be assigned or
\ntransferred or otherwise ceded or be pledged or hypothecated or be attached or
\nsubjected to any form of execution under a judgement or order of a court of law.
\n14.12 Medihelp or its contracted managed healthcare organisation may withhold, suspend or
\ndiscontinue the payment of a benefit to which a member is entitled under these Rules or
\nany right in respect of such benefit or payment of such benefit to such a member, if a
\nmember attempts to assign or transfer or otherwise cede or to pledge or hypothecate
\nsuch benefit.
\n15. Claim Procedures
\nValid claim
\n15.1 A claim must be submitted to Medihelp or its contracted managed healthcare
\norganisation within the prescribed period according to contractual stipulations in the case
\nof suppliers of service, and an account must be specified as follows in order to be
\nconsidered as a valid claim:
\n15.1.1 The surname and initials of the member.
\n15.1.2 The surname, first name, other initials (if any) and date of birth of the patient as indicated
\non the proof of membership.
\n15.1.3 The name of the scheme.
\n15.1.4 The membership number of the member.
\n15.1.5 The practice code number, group practice code number, and individual provider
\nregistration number issued by the relevant registering authorities for suppliers of
\nservices, if applicable, and in the case of a group practice, the name and practice code
\nnumber of the practitioner who rendered the services.
\n15.1.6 The date on which each service was rendered.
\n15.1.7 The nature and cost of each relevant health service and where such a supplier of service
\nsupplied medicine direct to such beneficiary, the name, quantity and dosage as well as
\nthe net amount payable by the member in respect of such medicine.
\n15.1.8 The relevant 5-character diagnostic ICD-10 code and such other item code numbers,
\nincluding CPT4, where applicable.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n15.
\n15.1.9 Where a pharmacist supplies medicine on prescription to a beneficiary, Medihelp may
\nrequest a copy of the original prescription or a certified copy of such prescription.
\n15.1.10 The name and practice code number of the referring\/prescribing medical practitioner or
\ndentist.
\n15.1.11 In the case where an account or statement refers to the use of an operating theatre
\n(where an operation was performed on the beneficiary) \u2013
\n15.1.11.1 the name, practice code number and registration number contemplated in rule 15.1.5 of
\nthe medical practitioner or dentist who performed the operation,
\n15.1.11.2 the name or names, practice code numbers and registration numbers contemplated in
\nrule 15.1.5 of every medical practitioner or dentist who assisted at such operation, and
\n15.1.11.3 the reference number provided by Medihelp or its contracted managed healthcare
\norganisation in the case of services that require pre-registration or pre-authorisation.
\n15.1.12 An account or statement in respect of orthodontic treatment or other advanced dentistry,
\na treatment plan indicating \u2013
\n15.1.12.1 the expected total amount that will be charged for the treatment;
\n15.1.12.2 the expected duration of the treatment;
\n15.1.12.3 the initial amount payable by the member; and
\n15.1.12.4 the monthly amount payable.
\n15.2 Where a member has paid an account, Medihelp or its contracted managed healthcare
\norganisation may require that the receipt issued by the supplier of service accompany
\nthe claim.
\n15.3 In the case of claims for services rendered abroad, an explanation\/exposition of the
\nservice as well as the name of the country in which the services were rendered must be
\nsupplied.
\n15.4 A claim arising from an accident or event in respect of which a beneficiary has received
\nor is likely to receive compensation from any source whatsoever must be accompanied
\nby an exposition of the conditions under which such injury or accident has arisen.
\nPrescribed period for the submission of claims
\n15.5 In order to qualify for benefits a claim must be submitted to Medihelp, its collector or its
\ncontracted managed healthcare organisation not later than the last day of the fourth
\ncalendar month following the month in which the service was rendered: provided that
\nMedihelp or its contracted managed healthcare organisation may extend the period in
\nthe case of a service rendered abroad.
\n15.6 If Medihelp or its contracted managed healthcare organisation is of the opinion that a
\nclaim is incorrect, incomplete or unacceptable for payment, Medihelp or its contracted
\nmanaged healthcare organisation shall inform the member and supplier of service within
\nthirty (30) days after receipt of such claim of the reasons for rejecting such claim and
\nafford the member and supplier of service an opportunity to submit an improved claim to
\nMedihelp, its collector or its contracted managed healthcare organisation within sixty (60)
\ndays following the date from which the notice of the rejection was issued.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n16.
\n15.7 It shall be the duty of a member to obtain accounts from a supplier of service for all
\nservices rendered and to ensure that all claims are submitted and finalised within the
\nprescribed submission period, irrespective of whether the supplier has undertaken to
\nsubmit the account to Medihelp or its contracted managed healthcare organisation.
\nShould a member be unable to obtain an account for services rendered because of the
\nextended nature of the treatment or for any other reason whatsoever, or if he has in fact
\nreceived an account but, because of circumstances beyond his control, is unable to
\nsubmit it within the prescribed submission period, Medihelp or its contracted managed
\nhealthcare organisation may extend the said period at its discretion, on condition that a
\nwritten application for extension is received by Medihelp or its contracted managed
\nhealthcare organisation before the expiration of the prescribed submission period.
\n15.8 Should a member be unable to submit a claim within the prescribed submission period
\ndue to the nature of his indisposition, Medihelp or its contracted managed healthcare
\norganisation may, at its discretion, and after satisfactory evidence has been given, grant
\nan extension of the said period.
\n15.9 Medihelp or its contracted managed healthcare organisation may at its discretion grant
\nan extension of the prescribed submission period when membership has ceased due to
\nthe death of a member.
\nPayment of amounts due to members and suppliers of service
\n15.10 Subject to the provisions of the Act, Medihelp or its contracted managed healthcare
\norganisation may decide whether Medihelp\u2019s contribution on the claim shall be in the
\nform of a direct payment to the supplier of service or to the member: provided that the
\nmethod used to conclude each claim\/corrected claim shall be shown clearly on the
\nsummarised claim statement sent to the member containing at least the following details:
\n15.10.1 The name and the membership number of the member.
\n15.10.2 The name of the supplier of service.
\n15.10.3 The date on which the service was rendered.
\n15.10.4 The amount charged by the supplier of service for the service.
\n15.10.5 The benefit amount for such service.
\n15.11 Payment of a claim shall be limited to the benefit allocation in respect of the relevant
\nservice as provided for in the applicable benefit option.
\n15.12 Payment of amounts due to a member or service provider shall be made by means of a
\ntransfer to a bank account at such recognised financial institution in the RSA as
\nfurnished to Medihelp by the member\/supplier of service, and Medihelp shall accept no
\nresponsibility\/liability for a payment made due to erroneous information furnished by the
\nmember\/supplier of service or outdated information in the possession of Medihelp.
\n15.13 Medihelp shall make a refund to a member where a member\u2019s credit amounts to R30.00
\nor more. On termination of the membership of a member, any amount of R5.00 or more
\nto his credit, shall be paid to the member.
\n15.14 In the event that Medihelp or its contracted managed healthcare organisation made a
\npayment in respect of a claim, a portion of a claim or any benefit to which the
\nbeneficiary\/former beneficiary is not entitled, such payment shall be reclaimed by
\nMedihelp from the member\/former member or supplier of service to whom the payment
\nwas made.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n17.
\n16. Liability of Members and Participating Employers
\n16.1 The liability of a participating employer to Medihelp shall be limited to the amounts
\npayable in terms of the agreement between the employer and Medihelp.
\n16.2 The liability of a member to Medihelp shall be limited to the amount of his subscription
\nowing as well as any other amount paid by Medihelp on behalf of the beneficiary and that
\nhas not been refunded to Medihelp.
\n16.3 In the case of a member whose membership has terminated, Medihelp shall be entitled
\nto recover any amount owing to Medihelp by such member.
\nJurisdiction
\n16.4 A magistrate\u2019s court shall have jurisdiction in any action or process which may be
\ninstituted against a member\/participating employer or former member\/participating
\nemployer for the recovery of amounts owing to Medihelp and\/or any other amount for
\nwhich the said member\/participating employer or former member\/participating employer
\nis liable or may become liable in future.
\n16.5 Should Medihelp, by virtue of the member\u2019s failure and\/or that of his dependants to
\nobserve the rules and\/or pay the amounts contemplated above, be compelled to institute
\nany legal action, the member shall be responsible to pay Medihelp\u2019s legal costs on an
\nattorney-client scale and collection commission and recovery costs as prescribed shall
\nbe payable, if applicable.
\n16.6 No agreement as contemplated in rule 11.6 shall encroach upon Medihelp\u2019s rights or in
\nany way be prejudicial thereto.
\n17. Governance
\nComposition of the Board of Trustees
\n17.1 The business of Medihelp shall be managed according to the Rules by a Board of
\nTrustees who is fit and proper to manage the business of Medihelp and is composed as
\nfollows:
\n17.1.1 Six (6) members of Medihelp elected at the annual general meeting for a period of three
\n(3) years from a list of nominated candidates.
\n17.1.2 Subject to section 57(2) of the Act, three (3) trustees of any medical scheme with which
\nMedihelp has amalgamated, according to an agreement with Medihelp, to serve on the
\nBoard of Trustees for an interim period until the next Annual General Meeting of
\nMedihelp.
\n17.1.3 Three (3) members of Medihelp co-opted by the Board of Trustees for a period of three
\n(3) years, on the grounds of their expert knowledge relating to the business of a medical
\nscheme: provided that such members shall not have the right to vote.
\n17.2 The following persons are not eligible to serve on the Board of Trustees:
\n17.2.1 a director, employee, officer, consultant, or contractor of the administrator of Medihelp, or
\nof the holding company, subsidiary, joint venture, or associate of the administrator of
\nMedihelp;
\n17.2.2 a broker;
\n17.2.3 the Principal Officer, the employees of Medihelp as contemplated in rule 25, and
\nindividuals who render services as contractors to Medihelp;
\n17.2.4 the auditor of Medihelp; and
\nRules as registered by the Registrar \u2013 Version 4.2010
\n18.
\n17.2.5 a person younger than twenty-one (21) years.
\nNomination and election of elected members
\n17.3 Any member of Medihelp may nominate a candidate who is a member of Medihelp,
\nexcluding those persons stated in rule 17.2, for election to the Board of Trustees on a
\nform as approved by the Board of Trustees.
\n17.4 Each nomination must be made on the form available from Medihelp, signed by the
\ncandidate, proposer and seconder (the latter two parties may not be the candidate) and
\nsubmitted to reach Medihelp before the close of business on the last working day of
\nMarch of each year. A nomination shall be invalid if \u2013
\n17.4.1 it is received after the closing date;
\n17.4.2 it is not completed in full; or
\n17.4.3 it is not signed by all three parties mentioned.
\n17.5 In the event of insufficient nominations having been received by the closing date
\nmentioned in rule 17.4, the annual general meeting may, in the manner prescribed for
\nthe holding of general meetings, nominate candidates for election to the Board of
\nTrustees.
\n17.6 A member of the Board of Trustees whose tenure of office expires shall be eligible for reelection.
\n17.7 The members at the annual general meeting can from the list of nominated candidates
\nelect a maximum of six (6) alternate members to the Board of Trustees.
\nTenure of Office
\n17.8 The tenure of office of members of the Board of Trustees commences when they are
\ndeclared properly elected, assigned or appointed.
\n17.9 The tenure of office of a member of the Board of Trustees ends when \u2013
\n17.9.1 he dies;
\n17.9.2 he resigns or when his assignment or appointment is revoked;
\n17.9.3 his membership of Medihelp terminates or is terminated in terms of rule 11;
\n17.9.4 he is declared insane or incapable of managing his affairs by a court;
\n17.9.5 his estate has been sequestrated or surrendered or allocated for the benefit of his
\ncreditors;
\n17.9.6 he is convicted, in the Republic of South Africa or elsewhere, of theft, fraud, forgery or of
\nuttering a forged document or of perjury;
\n17.9.7 he is found guilty of any offence and sentenced to imprisonment without the option of a
\nfine;
\n17.9.8 he is removed by a competent court of law from any office of trust on account of
\nmisconduct;
\n17.9.9 he is absent from three (3) consecutive meetings without the consent of the Chairman of
\nthe Board of Trustees;
\nRules as registered by the Registrar \u2013 Version 4.2010
\n19.
\n17.9.10 a motion of no confidence in a member is accepted by an annual general meeting or a
\nspecial general meeting with a two-thirds majority of members who are entitled to vote,
\nwho are either present in person or by proxy: provided that the stipulations of section 46
\nof the Act must be taken into consideration;
\n17.9.11 an annual general meeting takes place in the year that his tenure of office of three (3)
\nyears expires;
\n17.9.12 he is disqualified under any law from carrying on his profession;
\n17.9.13 he is removed from office by the Council for Medical Schemes in terms of the stipulations
\nof section 46 of the Act; and
\n17.9.14 he is removed from office by the Board of Trustees: provided that \u2013
\n17.9.14.1 before a decision is taken to remove the Board member, the Board shall furnish such
\nmember with full details of the information which the Board has in its possession
\nregarding the conduct of the member on which a complaint was received, and allow such
\nmember a period of not less than thirty (30) days to respond to the allegations;
\n17.9.14.2 the resolution to remove such member is taken by at least two thirds of the members of
\nthe Board of Trustees; and
\n17.9.14.3 the member shall have recourse to the disputes procedures of the Scheme or the
\ncomplaints and appeal procedures provided for in the Act.
\nFilling of vacancies on the Board of Trustees
\n17.10 The Board of Trustees has the power to fill any vacancy that may occur: provided that
\nvacancies shall only be filled from the list of nominated candidates laid before the most
\nrecent general meeting in sequence of candidates who recorded the most votes.
\n17.11 Should the members no longer constitute a quorum, a special general meeting shall be
\ncalled to fill such vacancy(ies).
\n17.12 Members so appointed shall hold office for the unexpired period of office of the retiring
\nmember.
\nElection of Chairman and Vice-Chairman
\n17.13 At the first meeting of the Board of Trustees after the annual general meeting, or after a
\nspecial general meeting referred to in rule 17.11, the members of the Board of Trustees
\nwith voting rights, shall, from the ranks of members with voting rights, elect a chairman
\nand a vice-chairman who shall be chairman and vice-chairman respectively of Medihelp
\nand who shall remain in office until after the following annual general meeting: provided
\nthat, should voting result in a tie, another election shall be held and should voting again
\nresult in a tie, the result will be determined by flipping a coin.
\nMeetings of the Board of Trustees
\n17.14 The Board of Trustees shall meet at least once every three months and such meetings
\nmay be held by telephone or electronic conferencing means.
\n17.15 The chairman, or in his absence the vice-chairman, may call additional meetings in order
\nto discuss specific matters, which matters shall be stated in the agenda. Any other two (2)
\nmembers of the Board of Trustees may request the chairman in writing to call a special
\nmeeting of the Board of Trustees to discuss specific matters, which matters shall be
\nstated in the agenda.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n20.
\n17.16 One (1) more than half of the total number of members entitled to vote that have been
\nappointed or elected to the Board of Trustees, constitute a quorum: provided that a
\nquorum may not be less than four (4) members.
\n17.17 Matters serving before the Board of Trustees are determined by a majority of votes and
\nin the event of a tie of votes, the chairman shall have a casting as well as a deliberative
\nvote.
\n17.18 In the event that both the chairman and the vice-chairman are absent from a meeting of
\nthe Board of Trustees, the members of the Board of Trustees shall appoint an acting
\nchairman from their ranks.
\nRemuneration
\n17.19 Members of the Board of Trustees shall be entitled to a honorarium for the execution of
\ntheir duties as members of the Board of Trustees: provided that the honorarium shall be
\npayable in accordance with the policy, as approved by the annual general meeting, for
\nattending meetings of the Board of Trustees and committees of the Board of Trustees.
\nAny other costs incurred by a member of the Board of Trustees on instruction of the
\nBoard of Trustees shall be payable in accordance with the policy as determined by
\nMedihelp.
\n18. Duties of the Board of Trustees
\n18.1 The Board of Trustees is responsible for the proper management of Medihelp in terms of
\nthe Rules of Medihelp.
\n18.2 The Board of Trustees shall act with due care, diligence, skill and in good faith.
\n18.3 Members of the Board of Trustees shall take all reasonable steps to avoid conflicts of
\ninterest and shall declare any interest they may have in a matter serving before the
\nBoard of Trustees.
\n18.4 The Board of Trustees shall apply sound business principles and shall see to it that the
\nfinancial soundness of Medihelp is maintained.
\n18.5 The Board of Trustees \u2013
\n18.5.1 must appoint the Principal Officer, who is fit and proper to hold such office: provided that
\na person shall not be the principal officer of Medihelp if that person is a director,
\nemployee, officer, consultant, or contractor of the administrator of Medihelp, or of the
\nholding company, subsidiary, joint venture, or associate of the administrator of Medihelp,
\nor a broker;
\n18.5.2 must remove the Principal Officer from office should any of the conditions stated in rule
\n17.9.1 to rule 17.9.9 be applicable to him;
\n18.5.3 can appoint any staff required for the proper execution of the business of Medihelp; and
\n18.5.4 must determine the conditions of service of the Principal Officer and any other person
\nemployed by Medihelp.
\n18.6 The chairman of the Board of Trustees must preside over meetings of the Board of
\nTrustees and shall ensure due and proper conduct at such meetings.
\n18.7 The Board of Trustees must cause minutes of the proceedings of all annual general
\nmeetings, special general meetings and meetings of the Board of Trustees, to be
\nrecorded and that the minutes of such meetings be submitted to the relevant subsequent
\nmeeting: provided that the minutes of a special general meeting shall be submitted to the
\nannual general meeting. Should the minutes of any such meetings be accepted and
\nconfirmed as correct, it must be signed by the chairman.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n21.
\n18.8 The Board of Trustees must ensure that proper control systems are employed by or on
\nbehalf of Medihelp.
\n18.9 The Board of Trustees must ensure that adequate and appropriate information is
\ncommunicated to the members of Medihelp regarding their rights, benefits, contributions
\nand duties in terms of the Rules of Medihelp.
\n18.10 The Board of Trustees must take all reasonable steps to ensure that contributions are
\npaid timeously to Medihelp in accordance with the Act and the Rules.
\n18.11 The Board of Trustees must take out and maintain an appropriate level of professional
\nindemnity insurance and fidelity guarantee insurance.
\n18.12 The Board of Trustees must obtain expert advice on legal, accounting and business
\nmatters as required, or on any other matter of which the members of the Board of
\nTrustees may lack sufficient expertise.
\n18.13 The Board of Trustees must ensure that the Rules, operation and administration of
\nMedihelp comply with the provisions of the Act and all other applicable laws.
\n18.14 The Board of Trustees must take all reasonable steps to protect the confidentiality of
\nmedical records concerning any beneficiary\u2019s state of health.
\n18.15 The Board of Trustees must see to it that all disbursements are properly authorised.
\n18.16 The Board of Trustees must cause to be kept in safe custody, in a safe or strong-room at
\nthe registered office of Medihelp or with any financial institution approved by the Board of
\nTrustees, any mortgage bond, title deed or other security belonging to or held by
\nMedihelp, except when in the temporary custody of another person for the purposes of
\nMedihelp.
\n18.17 The Board of Trustees must cause to be kept such books of accounts, accounts and
\nregisters that are necessary for the proper functioning of Medihelp.
\n18.18 The members of the Board of Trustees shall disclose annually in writing to the Registrar
\nany payment or considerations made to them by Medihelp.
\n18.19 Details of the remuneration and allowances paid to members of the Board of Trustees,
\nwhich must be included in the annual financial statements in terms of regulation 6A of the
\nAct, must be published in detail in the documentation for the Annual General Meeting
\ncirculated to members, and must indicate the number and nature of the meetings
\nattended by every member of the Board of Trustees.
\n19. Powers of the Board of Trustees
\nThe Board of Trustees has the following powers:
\n19.1 To act in the name of Medihelp and to enter into contracts (including, but not confined to,
\ncontracts concerning the purchase, mortgage, hire, lease and alienation of immovable
\nproperty, rendering of services to members and the direct submission of accounts to
\nMedihelp by suppliers of service, on behalf of members and the direct payment of
\naccounts to suppliers of service on their behalf) and to transact all such business which
\nis advantageous for the achievement of the objectives and proper management of
\nMedihelp.
\n19.2 To appoint a duly accredited administrator on such terms and conditions as determined
\nby the Board of Trustees, for the proper execution of the business of Medihelp, which
\nappointment shall be contained in a written contract, which complies with the
\nrequirements of the Act and the Regulations.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n22.
\n19.3 To institute and defend any lawsuit which may be necessary for safeguarding the interest
\nof Medihelp.
\n19.4 To invest funds to obtain direct or indirect interest in an institution\/enterprise which
\nrenders a \u201cservice\u201d, and lend, invest, put out on interest, deposit, advance or otherwise
\ndeal with such money as is not immediately required to cover the current expenditure of
\nMedihelp, upon such security and in such manner as the Board of Trustees may
\ndetermine, and to realise such investment, vary, re-invest or otherwise deal therewith as
\nthe Board of Trustees may determine.
\n19.5 To borrow money on current account from Medihelp\u2019s bankers against the security of the
\nassets of Medihelp if approved by the Council for Medical Schemes.
\n19.6 To maintain reserve funds and determine the amounts thereof from time to time.
\n19.7 To appoint, compensate and determine the level of services of any broker for the
\nintroduction and retention of a member of Medihelp.
\n19.8 To appoint at its discretion a collector for Medihelp under such conditions as it may
\ndetermine.
\n19.9 To utilise funds for the purpose of promoting the objectives of Medihelp and make
\ncontributions to any association instituted for the benefit of medical schemes.
\n19.10 To appoint the Principal Officer and other staff in accordance with such conditions as the
\nBoard of Trustees may from time to time determine, and take all necessary steps to sign
\nand execute all documents required to ensure and secure the due fulfilment of
\nMedihelp\u2019s obligations under such appointments.
\n19.11 To suspend or terminate the services of any employee of Medihelp: provided that the
\ntermination of the services of the Principal Officer shall require to be approved by at least
\ntwo-thirds of the full Board of Trustees.
\n19.12 To approve, whenever a member is able to satisfy the Board of Trustees that he, for
\nreasons acceptable to the Board of Trustees, could not comply with the provisions of a
\nrule and has consequently been prejudiced thereby, that the benefits such member
\nwould have received had he complied with the rule concerned, be granted to him.
\n19.13 To decide, at its discretion, on any matter not specifically covered by the Rules: provided
\nthat in the execution of this discretion the Board of Trustees shall be bound by the
\nobjectives of Medihelp, the Rules and the stipulations of the Act.
\n19.14 To appoint a committee composed of such members of the Board of Trustees and other
\nexperts as it may deem fit and delegate any of its powers, with the exception of rules
\n19.18 and 19.19, to such committee or the Principal Officer: provided that \u2013
\n19.14.1 any committee so formed or the Principal Officer must, in the exercise of such powers,
\ncomply with any rules or instructions that may be imposed or issued by the Board of
\nTrustees; and
\n19.14.2 any powers delegated as such may at any time be amended or retracted by the Board of
\nTrustees.
\n19.15 To authorise the Principal Officer and\/or such other members of the Board of Trustees,
\nupon such conditions as the Board of Trustees may determine, to sign any contract or
\nother document binding on or relating to Medihelp, or any document authorising the
\nperformance of any act on behalf of Medihelp.
\n19.16 To transfer to the funds of Medihelp any unclaimed moneys still outstanding after the
\nexpiry of a period of three (3) years from the date of payment.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n23.
\n19.17 To amend, rescind or add rules, subject to the stipulations of rule 31.
\n19.18 To implement subscription per benefit option on the basis of the member’s income and\/or
\nthe number of dependants, and to decrease or increase subscription to the extent that it
\nmay be deemed necessary to ensure the financial stability of Medihelp, subject to rule
\n31.1.4.
\n19.19 To establish or operate, subject to the provisions of any law, on its own or in association
\nwith any other person, any pharmacy, hospital, clinic, maternity home, nursing home,
\ninfirmary, home for aged persons or, with the approval of the Minister, any similar
\ninstitution, in the interest of the members of Medihelp.
\n19.20 To make donations to any hospital, clinic, nursing home, maternity home, infirmary or
\nhome for aged persons, in the interest of the members of Medihelp.
\n19.21 To enter into agreements with managed healthcare organisations, subject to the Act and
\nthe Regulations.
\n19.22 To contribute to a fund of any kind whatsoever which is conducted for the benefit of
\nemployees of Medihelp or to pay for insurance policies on the lives of officers of
\nMedihelp for the benefit of such officers or their dependants.
\n19.23 To reinsure obligations in terms of the benefits provided for in the Rules: provided that all
\nsuch reinsurance arrangements are fully disclosed to the Council for Medical Schemes.
\n19.24 To introduce, change or abolish benefit options.
\n20. Indemnity
\nThe Board of Trustees and any employee of Medihelp shall be indemnified by Medihelp against all
\nlegal proceedings, costs and expenses incurred by reason of any claim in connection with the
\nactivities of Medihelp that cannot be ascribed to negligence, dishonesty or fraud.
\n21. Fidelity Guarantee
\nThe Board of Trustees shall ensure that Medihelp is insured against loss arising from fraud or
\ndishonesty of any of its employees, including the Board of Trustees, who receives or controls the
\nfunds or securities of Medihelp.
\n22. Financial Year
\nThe financial year of Medihelp extends over each period of twelve (12) calendar months ending on
\n31 December.
\n23. Bank Account
\n23.1 Medihelp shall maintain a bank account with a registered commercial bank as decided by
\nthe Board of Trustees.
\n23.2 All moneys received shall be paid into this account and all payments shall be made in
\nsuch manner and in such form as stipulated in the Rules.
\n23.3 Payments from the account shall be authorised by such members of the Board of
\nTrustees or employees of Medihelp as empowered thereto from time to time by the
\nBoard of Trustees.
\n24. Custody of Records
\n24.1 Records of transactions with members must be kept in custody for a period of three (3)
\nyears. All other records must be kept for a period determined by the Board of Trustees.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n24.
\n24.2 Medihelp shall not reply to any enquiry concerning transactions of which the records
\nhave already been destroyed and in such a case Medihelp shall accept no responsibility
\nfor any loss suffered by or obligation imposed on a member.
\n25. Duties of the Principal Officer and Staff
\n25.1 The Principal Officer shall ensure that \u2013
\n25.1.1 the decisions and instructions of the Board of Trustees are executed without
\nunnecessary delay;
\n25.1.2 there is proper communication between Medihelp and those parties affected by the
\ndecisions and instructions of the Board of Trustees;
\n25.1.3 he keeps the Board of Trustees sufficiently and timeously informed of the business of
\nMedihelp which relates to the duties of the Board of Trustees as stated in section 57(4)
\nof the Act;
\n25.1.4 he keeps the Board of Trustees sufficiently and timeously informed of the business of
\nMedihelp so as to enable the Board of Trustees to comply with the provision of section
\n57(6) of the Act; and
\n25.1.5 he does not take any decisions concerning the business of Medihelp without prior
\nauthorisation by the Board of Trustees and that he observes the authority of the Board of
\nTrustees in its governance of the business of Medihelp.
\n25.2 The Principal Officer shall be the accounting officer of Medihelp charged with the
\ncollection and depositing of all moneys received and the making of payments authorised
\nby the Board of Trustees, and shall ensure that proper record is kept of all financial
\ntransactions as well as the assets and liabilities of Medihelp.
\n25.3 The Principal Officer shall perform the tasks required for the proper administration of the
\nbusiness of Medihelp and must attend all meetings of Medihelp, the Board of Trustees
\nand any other properly appointed committee at which his presence is required and he
\nmust ensure that the proceedings at all meetings are properly minuted.
\n25.4 The Principal Officer must ensure that the financial statements of Medihelp are prepared
\nand that it complies with the related statutory requirements.
\n25.5 The Principal Officer shall be responsible to supervise the staff of Medihelp, unless
\notherwise decided by the Board of Trustees.
\n25.6 The staff of Medihelp shall ensure the confidentiality of information concerning the
\nmembers of Medihelp and service providers.
\n25.7 In the absence of the Principal Officer or in the event of him being otherwise unavailable,
\nan Executive Officer or other duly empowered substitute, appointed by the Board of
\nTrustees, shall act in his place and perform his duties.
\n25.8 The Principal Officer can delegate his delegated responsibilities, with the exception of
\nthose as indicated by the Board of Trustees, to any other employee of Medihelp.
\n26. Auditor and Audit Committee
\n26.1 An auditor (who must be approved in terms of section 36 of the Act) must be appointed
\nat each annual general meeting for a period of one (1) year to the conclusion of the next
\nannual general meeting.
\n26.2 The following persons shall not be appointed as an auditor of Medihelp \u2013
\nRules as registered by the Registrar \u2013 Version 4.2010
\n25.
\n26.2.1 a person who is a member of the Board of Trustees;
\n26.2.2 a person who is otherwise employed as an employee, officer or contractor of Medihelp;
\n26.2.3 a person who is an employee, director, officer or contractor of Medihelp\u2019s administrator,
\nor of the holding company, subsidiary, joint venture or associate of its administrator;
\n26.2.4 a person who is not engaged in public practice as an auditor; or
\n26.2.5 a person who is disqualified from acting as an auditor in terms of the Companies Act,
\n1973.
\n26.3 Should an auditor not be appointed or reappointed at the annual general meeting, the
\nBoard of Trustees must, within thirty (30) days of the date of the meeting, appoint an
\nauditor to fill the vacancy and should it fail to do so, the Registrar of Medical Schemes
\nmay do so at any time.
\n26.4 Should the appointment of the auditor terminate during the year, the Board of Trustees
\nshall appoint another auditor within thirty (30) days, and, if it fails to do so, the Registrar
\nof Medical Schemes may do so at any time. The auditor thus appointed shall relinquish
\nhis office at the conclusion of the first annual general meeting subsequent to his
\nappointment.
\n26.5 The auditor of Medihelp shall at all times have the right of access to the books, records,
\naccounts and documents of Medihelp and is entitled to obtain from the Board of Trustees
\nand officers of Medihelp such information as he may deem necessary for the
\nperformance of his duties.
\n26.6 The auditor must report to the members of Medihelp on the accounts examined by him
\nand on the financial statements submitted to the annual general meeting.
\n26.7 The Board of Trustees must appoint an audit committee.
\n27. Annual General Meeting
\n27.1 The annual general meeting of members shall be held on or before 30 June annually and
\nshall be convened by the Principal Officer on instruction of the Board of Trustees.
\n27.2 The notice convening the annual general meeting together with the agenda, annual
\nreport, report by the Board of Trustees which gives an overview of the financial
\nstatements and notice that copies of the most recent annual financial statements will be
\ndispatched to members on request and are available at Medihelp’s head office and on
\nMedihelp’s website as stipulated in the Act, proxy form, any notice of motions\/proposals
\nsupported by the documentation as contemplated in rule 27.2.2.1, the list of nominated
\ncandidates for election to the Board of Trustees and the curriculum vitae of each
\ncandidate shall be sent to all members, at least thirty (30) days prior to the date of the
\nmeeting, direct or through the medium of their employers: provided that \u2013
\n27.2.1 the non-receipt of such notice by a member shall not invalidate the proceedings of an
\nannual general meeting; and
\n27.2.2 in the event of motions\/proposals to be voted on \u2013
\n27.2.2.1 such notice of motion or proposal is fully documented and motivated; and
\n27.2.2.2 the motion or proposal must be received by the Principal Officer before the close of
\nbusiness on the last working day of March annually.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n26.
\n27.3 Thirty-one (31) members of Medihelp present in person at the meeting shall be a
\nquorum. If a quorum is not present after the lapse of half an hour from the time fixed for
\nthe commencement of the meeting, the meeting shall be postponed until the
\ncorresponding day and time of the following week, and the members then present shall
\nconstitute a quorum: provided that, if the corresponding day of the following week is a
\npublic holiday, the meeting shall be postponed to the first working day thereafter.
\n27.4 The chairman, or in his absence the vice-chairman of the Board of Trustees shall be
\nchairman of the annual general meeting. In their absence, the chairman shall be elected
\nfrom the members present.
\n27.5 Subject to the stipulations of rule 29, the annual general meeting or a special general
\nmeeting, as the case may be, must decide on the following matters:
\n27.5.1 Election of members to the Board of Trustees in terms of rule 17.
\n27.5.2 Appointment of an auditor in terms of rule 26.
\n27.5.3 Date of implementation of rule amendments.
\n27.5.4 Rule amendments as described in rule 31.
\n27.5.5 Dissolution in accordance with rule 32.
\n27.5.6 Amalgamations and transfers in accordance with rule 33.
\n27.5.7 Any other matter which is submitted in terms of the Rules.
\n27.6 The financial statements and accompanying reports as contemplated in rule 27.2 must
\nbe laid before the meeting.
\n28. Special General Meeting
\n28.1 Should the Board of Trustees deem it necessary, or on receipt of a written request,
\nsupported by at least thirty-one (31) members of Medihelp who are entitled to vote, the
\nBoard of Trustees shall, within ninety (90) days of the receipt thereof, convene a special
\ngeneral meeting. The petition must indicate the matters for discussion and must be
\nsigned by all the petitioners. Only those matters for which the meeting was convened
\nmay be discussed.
\n28.2 In the case of proposals\/motions on which voting is required, the motions\/proposals shall
\nbe documented in detail, which complete documentation and motivations shall be
\nincluded in the notice of the special annual general meeting which must be circulated to
\nall members.
\n28.3 Notice of a special general meeting must be sent to all members, together with the
\nagenda and form of proxy and the documentation contemplated in rule 28.2, if voting on
\nmatters is required, at least thirty (30) days before the day of the meeting, either direct or
\nthrough the medium of their employers.
\n28.4 Thirty-one (31) members of Medihelp who are entitled to vote and present in person at
\nthe meeting shall be a quorum. If a quorum is not present after the lapse of half an hour
\nfrom the time fixed for the commencement of the meeting, the meeting shall be
\npostponed until the corresponding day and time of the following week and the members
\npresent shall constitute a quorum: provided that \u2013
\n28.4.1 if the corresponding day of the following week is a public holiday, the meeting shall be
\npostponed to the first working day thereafter; and
\nRules as registered by the Registrar \u2013 Version 4.2010
\n27.
\n28.4.2 if a quorum is not present after the lapse of half an hour from the time fixed for the
\ncommencement of a meeting convened on request of the members, the meeting shall be
\nconsidered cancelled.
\n29. Voting at General Meetings
\n29.1 Every member whose subscriptions are paid up and who is present at an annual general
\nmeeting or special general meeting shall be entitled to vote or may, subject to this rule,
\nappoint another member of the Scheme as a proxy to attend, speak and vote at the
\nmeeting in his stead as indicated in the proxy form. In the event of voting by means of a
\nballot, every member present in person or represented by a proxy shall be entitled to
\nvote. The chairman shall have a normal as well as a casting vote.
\n29.2 Election of members to the Board of Trustees shall, when a vote is necessary, take place
\nby means of a ballot. The names of the candidates shall be entered in alphabetical order
\non the ballot papers and a vote shall be recorded by making a cross against the name of
\neach candidate for whom a vote is cast. Voting and the counting of votes shall be
\nexecuted in accordance with the procedure as set out in Schedule E. A ballot paper shall
\nbe considered spoilt in its entirety if \u2013
\n29.2.1 the form is submitted without any votes indicated;
\n29.2.2 it is not signed; or
\n29.2.3 it is not completed in ink,
\nand in respect of a particular item to be voted on, the vote in respect of the item shall be
\nspoilt if the member who casts the vote \u2013
\n29.2.4 exercised more choices than the number of options permitted on the ballot paper; and\/or
\n29.2.5 alters his choice but fails to initial the alteration.
\n29.3 Voting during the meeting on administrative arrangements for holding the meeting shall
\nonly be by members who are entitled to vote and present in person at the meeting, and
\nshall be by the show of hands.
\n29.4 Resolutions adopted at a general meeting shall be binding on all members of Medihelp.
\nProxy
\n29.5 The document (hereafter referred to as the form of proxy) to appoint a person to act as
\nproxy must meet the following requirements, failing which the proxy shall be invalid in its
\nentirety. The form of proxy should be \u2013
\n29.5.1 in writing;
\n29.5.2 completed and signed by the warrantor;
\n29.5.3 signed by the person who acts as proxy; and
\n29.5.4 in the format as determined by the Board of Trustees.
\n29.6 A person who acts as proxy must be a member of Medihelp and must be entitled to vote
\nat any annual general meeting or special general meeting.
\n29.7 The original form of proxy must be delivered to the nominated office at least five (5)
\nworking days before the time for holding the annual general meeting or the special
\ngeneral meeting on which the warrantor wants to vote. Should a member fail to comply
\nwith this provision, the form of proxy shall not be considered valid.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n28.
\n29.8 For the purpose of rule 29.7 a working day shall be deemed to exclude Saturdays,
\nSundays and public holidays.
\n30. Settlement of Complaints and Disputes
\n30.1 Members may lodge their complaints, in writing, to Medihelp, which complaints shall be
\nresponded to by Medihelp in writing within thirty (30) days.
\n30.2 The Principal Officer shall refer any dispute arising between Medihelp and a member or
\nformer member or prospective member out of the administration and decisions of
\nMedihelp to the Disputes Committee for settlement.
\n30.3 The Disputes Committee comprising three (3) committee members, of which at least one
\n(1) committee member must be a person with legal expertise, shall be convened from a
\npanel of persons appointed by the Board of Trustees for a period of one (1) year, which
\nmembers of the committee shall not be members of the Board of Trustees, employees of
\nMedihelp or employees of the administrator of Medihelp: provided that the committee
\nmembers shall be remunerated as determined by the Board of Trustees for attending a
\nsitting of the committee.
\n30.4 On receipt of a request for the settlement of a dispute, the Principal Officer shall convene
\na meeting of the Disputes Committee by giving not less than twenty-one (21) days\u2019 notice
\nin writing prior to the meeting to the complainant and all the persons serving on the
\nDisputes Committee, stating the date, venue and particulars of the dispute.
\n30.5 A dispute must be submitted to the Principal Officer, fully documented by the person
\nconcerned and the discrepancy out of the administration and decisions of Medihelp must
\nbe reasoned out in terms of the Rules.
\n30.6 The Disputes Committee shall determine the procedure to be followed when hearing the
\ndispute.
\n30.7 The parties to the dispute have the right to be heard at the proceedings, either in person
\nor through a representative.
\n30.8 An aggrieved person shall have the right to appeal to the Council for Medical Schemes
\nagainst the decision of the Disputes Committee, which appeal shall be in the form of an
\naffidavit directed to the Council for Medical Schemes and shall be furnished to the
\nRegistrar of Medical Schemes within three (3) months after the date on which the
\ndecision of the Disputes Committee was made.
\n31. Amendment of Rules
\n31.1 The Board of Trustees has the authority to amend or delete any rule and any Schedule
\nto the Rules, or to implement new rules and Schedules to the Rules: provided that \u2013
\n31.1.1 no amendment, deletion or addition to the Rules pertaining to the objectives of Medihelp
\nshall be valid unless it has been approved by the majority of members who are entitled to
\nvote, who are either present in person or by proxy at the annual general meeting or
\nspecial general meeting;
\n31.1.2 the correction of any error of spelling, language, translation, punctuation or grammatical
\nerrors in the Rules, rearranging and renumbering of rules shall not be regarded as being
\nan amendment or rescission of, or addition to the Rules;
\nRules as registered by the Registrar \u2013 Version 4.2010
\n29.
\n31.1.3 no amendment, rescission or addition to rules 16 (LIABILITY OF MEMBERS AND
\nPARTICIPATING EMPLOYERS), 17 (GOVERNANCE), 18 (DUTIES OF THE BOARD
\nOF TRUSTEES), 19 (POWERS OF THE BOARD OF TRUSTEES), 26 (AUDITOR AND
\nAUDIT COMMITTEE), 27 (ANNUAL GENERAL MEETING), 28 (SPECIAL GENERAL
\nMEETING), 29 (VOTING AT GENERAL MEETINGS), 30 (SETTLEMENT OF
\nCOMPLAINTS AND DISPUTES), 32 (DISSOLUTION) and 33 (AMALGAMATION AND
\nTRANSFER) shall be valid unless it has been approved by two-thirds of the members
\nwho are entitled to vote, who are either present in person or by proxy at a general
\nmeeting; and
\n31.1.4 no amendment, rescission or addition shall be valid unless it has been approved by the
\nRegistrar of Medical Schemes.
\n31.2 A member must, within sixty (60) days after the registration of a rule amendment, be
\ninformed in writing of such registration, and in case of an amendment of a member\u2019s
\nrights, responsibilities, subscription, the benefits to which he is entitled or any other
\ncondition affecting his membership, he shall be informed in writing at least thirty (30)
\ndays before implementation: provided that the non-receipt of notification of a rule
\namendment shall in no way relieve a member of any obligations that may arise from such
\namendment.
\n31.3 Notwithstanding the stipulations of rule 31.1 the Board of Trustees must, on request and
\nto the satisfaction of the Registrar of Medical Schemes, amend any rule that is contrary
\nto the stipulations of the Act.
\n32. Dissolution
\n32.1 The Scheme may be dissolved by order of a competent court or by voluntary dissolution.
\n32.2 The members at a general meeting of Medihelp may decide that the Scheme must be
\ndissolved, in which event the Board of Trustees must arrange for members to decide by
\nballot whether Medihelp must be liquidated.
\n32.3 Pursuant to a decision by members taken in terms of rule 32.2, the Principal Officer, in
\nconsultation with the Registrar of Medical Schemes, must furnish every member with a
\nmemorandum explaining the reasons for the proposed dissolution and setting forth the
\nproposed basis of distribution of the assets in the event of winding up, together with a
\nballot paper.
\n32.4 Every member must be requested to return his ballot paper duly completed before a set
\ndate. If at least fifty (50) per cent of the members return their ballot papers duly
\ncompleted and if the majority thereof is in favour of the dissolution of the Scheme, the
\nBoard must ensure compliance therewith and appoint, subject to the approval of the
\nRegistrar of Medical Schemes, a competent person as liquidator.
\n33. Amalgamation and Transfer
\n33.1 Medihelp may, subject to the provisions of section 63 of the Act, amalgamate with,
\ntransfer its assets and liabilities to, or take transfer of assets and liabilities of any other
\nmedical scheme or person, in which event the following process shall be followed: If the
\nBoard of Trustees is of the opinion that Medihelp should amalgamate or transfer, the
\nPrincipal Officer shall, on instruction of the Board of Trustees, send to every member,
\ndirect or through the medium of his employer, a memorandum setting out the reasons for
\nsuch action together with a ballot paper: provided that the non-receipt by a member of
\nthe said memorandum and ballot paper shall not invalidate any action taken in terms of
\nthis paragraph. Every member shall be requested to return his ballot paper properly
\ncompleted before a fixed date. If the majority of the properly completed ballot papers
\nreturned to Medihelp are in favour of amalgamation or transfer, the Board of Trustees
\nshall take a formal decision to amalgamate or transfer.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n30.
\n33.2 If a decision to amalgamate or transfer has been taken in accordance with rule 33.1, the
\namalgamation or transfer shall be concluded in terms of the stipulations of section 63 of
\nthe Act.
\n34. Right To Obtain Documents And Inspection Of Documents
\n34.1 A beneficiary must on request be supplied with the following documents \u2013
\n34.1.1 the Rules of Medihelp;
\n34.1.2 the latest audited annual financial statements, returns, Board of Trustees\u2019 report and
\nauditor\u2019s report; and
\n34.1.3 accompanying management accounts in respect of the various benefit options of
\nMedihelp.
\n34.2 A beneficiary is entitled to inspect at the registered office of Medihelp any document
\nreferred to in rule 34.1 and to make extracts therefrom.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n31.
\nMEDIHELP RULES: SCHEDULEA
\nSubscriptions, Contributions to a Personal Medical Savings Account and
\nPenalties for Persons Joining Late in Life
\nSubscriptions
\n1. The subscriptions stated in paragraph 2, together with the contribution to the personal
\nmedical savings account contemplated in paragraph 3, as well as any applicable
\nsubscription penalty contemplated in paragraph 5, shall be payable per calendar month
\nor part thereof.
\n2. Monthly subscriptions for the various benefit options, including the contribution to the
\npersonal medical savings account, are as follows with effect from 1 January 2010:
\nMEDIHELP
\nPLUS
\nDIMENSION
\nELITE
\nDIMENSION
\nPRIME 3
\nDIMENSION
\nPRIME 2
\nDIMENSION
\nPRIME 1
\nMember R3,600 R1,800 R1,320 R1,098 R762
\nDependant R3,600 R1,680 R1,134 R912 R624
\nDependent child younger
\nthan 26 years R894 R486 R396 R336 R234
\nUNIFY
\nMonthly income R3,000 and less R3,001 to R5,000 R5,001 to R7,000 R7,001 to R9,000 R9,001 and more
\nMember R923 R1,030 R1,238 R1,335 R1,649
\nDependant R720 R942 R1,164 R1,217 R1,270
\nDependent child younger
\nthan 24 years R106 R120 R151 R160 R166
\nNECESSE
\nMember R642
\nDependant R504
\nDependent child younger
\nthan 21 years R276
\n2.1 In the case of the Dimension Prime 1, 2 and 3 benefit options subscriptions are payable
\nin respect of dependent children younger than 26 years, to a maximum of two (2)
\nregistered children, irrespective of the number of such children registered.
\n2.2 In those cases where the subscriptions for a benefit option are based on income, proof of
\nmonthly income must be supplied to Medihelp in a manner which is acceptable to
\nMedihelp. If acceptable proof of income is not supplied, subscriptions shall be calculated
\naccording to the next highest income category. Should proof of income be supplied at a
\nlater stage, subscriptions shall be adjusted from a current date with effect from the month
\nfollowing the month in which proof of income is supplied: provided that the Principal
\nOfficer may, in his sole discretion, decide on a different date.
\nContributions to a personal medical savings account
\n3. The monthly contributions to the personal medical savings account which are included
\nwith the monthly subscriptions are as follows with effect from 1 January 2010:
\nRules as registered by the Registrar \u2013 Version 4.2010
\n32.
\nDIMENSION PRIME 2
\nMember R216.00
\nDependant R180.00
\nDependent child younger
\nthan 26 years R66.00
\n4. A personal medical savings account is only applicable in the case of the Dimension
\nPrime 2 benefit option.
\nSubscription penalties for persons joining late in life
\n5. Should a late-joiner penalty be applied to a beneficiary, the applicable penalty band, as
\nexplained in paragraph 5, shall be calculated according to the following formula:
\n5.1 Penalty band = B minus (35 + C), where \u2013
\n5.1.1 \u201cB\u201d means the age of the late joiner at the time of his enrolment as a beneficiary; and
\n5.1.2 \u201cC\u201d means the proven number of completed 12-month periods of membership of one or
\nmore medical schemes.
\n6. Table of penalty bands and maximum subscription penalty:
\nPENALTY BANDS SUBSCRIPTION PENALTY
\n1 to 4 years 0.05 of subscription
\n5 to 14 years 0.25 of subscription
\n15 to 24 years 0.50 of subscription
\n25 years and more 0.75 of subscription
\n7. For the purpose of producing evidence of previous membership, it shall be sufficient
\nproof if the beneficiary produces a statement in which he declares \u2013
\n7.1 the name or names of the relevant medical schemes and the relevant periods in which
\nhe was a registered beneficiary; and
\n7.2 the reasonable efforts that have been made to obtain documentary evidence of such
\nmembership, but have been unsuccessful.
\n8. Where a beneficiary produces acceptable evidence of previous membership as a
\nbeneficiary to Medihelp after a late-joiner penalty has been imposed, Medihelp must
\nrecalculate the late-joiner penalty and apply such revised penalty, if any, from the
\nbeginning of the calendar month following the month in which such evidence is received
\nby Medihelp: provided that if proof is provided within six (6) months after enrolment, the
\nexcess penalties levied may be refunded to the member.
\n9. Medihelp shall continue to apply a late-joiner penalty that was applied to a beneficiary on
\nhis enrolment at the medical scheme from which the beneficiary transfers to Medihelp.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n33.
\nMEDIHELP RULES: SCHEDULEB
\nServices and the Maximum and Minimum Granting of Benefits
\nand Interchange between Benefit Options with effect from 1 January 2010
\n1. With the exception of the exclusions listed in Schedule C, Schedule C.1 and Schedule
\nC.2, Medihelp shall grant benefits per benefit option in respect of services rendered as
\nset out in Schedules B1 to B7.
\n2. Where a maximum amount is imposed on benefits payable during a financial year \u2013
\n2.1 benefits shall be calculated on the services rendered during the financial year concerned,
\nand no adjustments by means of debiting a claim against a preceding or following
\nfinancial year, shall be made;
\n2.2 such maximum amount and the savings protector, excluding maximum benefits applied
\nper case, shall be calculated on a pro rata basis from the date of enrolment as a
\nbeneficiary to the end of the financial year;
\n2.3 any unexpended benefits shall not, in the event of a change of benefit option, be
\ntransferred from the previous to the next benefit option(s); and
\n2.4 the application of maximum benefits shall mean the following: provided that the balance
\navailable for any benefit at the end of a financial year may not be carried forward to the
\nfollowing financial year:
\n2.4.1 \u201cPer family\u201d shall mean a member and all his registered dependants collectively.
\n2.4.2 \u201cPer beneficiary\u201d shall mean each individual beneficiary separately.
\n2.4.3 \u201cPer case\u201d shall mean \u2013
\n2.4.3.1 in relation to an implanted prosthesis, the total cost of all the components of every
\ncomplete prosthesis;
\n2.4.3.2 in relation to emergency transport services, every occasion which requires a beneficiary
\nto be transported by means of emergency transport for reasons which are medically
\njustified; and
\n2.4.3.3 in relation to a sex change operation, every occasion on which a surgical intervention
\ntakes place.
\n2.4.4 \u201cPooled benefit\u201d shall mean the total rand value of the benefit per beneficiary multiplied
\nby the number of beneficiaries, which is available for any of the beneficiaries, irrespective
\nof which beneficiary uses the benefit.
\n2.4.5 “Cycle” shall mean the stated length of the benefit cycle calculated in relation to any
\nperiod of uninterrupted membership of Medihelp, regardless of any interchange between
\nbenefit options during such uninterrupted period of membership of Medihelp.
\n3. Interchange between benefit options
\n3.1 Interchange between benefit options may only occur with effect from the beginning of the
\nsubsequent financial year, if Medihelp receives the member\u2019s written request before
\n1 December: provided that Medihelp, at its own discretion, may approve the interchange
\nbetween benefit options where groups or individuals request such change in writing to be
\nimplemented with effect from a date determined by Medihelp.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n34.
\n3.2 In the case of a beneficiary who is diagnosed for the first time with a chronic condition for
\nwhich his present benefit option offers insufficient or no benefits, such member may
\napply to change to the Medihelp Plus benefit option, subject to the following conditions:
\n3.2.1 The request for interchange must reach Medihelp within 60 days after the chronic
\ncondition was diagnosed.
\n3.2.2 The request for interchange must be accompanied by \u2013
\n3.2.2.1 A description of the chronic condition, including the ICD-10 code;
\n3.2.2.2 the date on which the condition was first diagnosed;
\n3.2.2.3 the applicable medical reports supporting the diagnosis;
\n3.2.2.4 the treatment received since the condition was first diagnosed; and
\n3.2.2.5 the prescribed future treatment plan, including a completed MEDICHRON application
\nform should chronic medicine be prescribed.
\n3.2.3 If approved, the benefit option of the member and his dependants shall change from the
\nbeginning of the month following the month in which the application was received.
\n4. Protocols
\n4.1 Medihelp shall allocate benefits according to the protocol(s) that apply for the following,
\nwhich protocols are available on request: provided that co-payments shall apply per
\nbenefit option, as per paragraph 5 of Schedule B, for the treatment of non-PMB
\nconditions, if the treatment voluntarily deviates from the applicable protocol(s) or services
\nare voluntarily obtained outside the designated service provider network. In the case of
\nPrescribed Minimum Benefits, the co-payments as explained in Annexure 2 shall be
\napplicable:
\n4.1.1 Treatment of chronic renal failure.
\n4.1.2 Private nursing.
\n4.1.3 EVARS prostheses.
\n4.1.4 Oncology.
\n4.1.5 Prescribed minimum benefits.
\n4.1.6 Medicine used for indications other than for what it has been registered by the South
\nAfrican Medicines Control Council.
\n4.1.7 Positron Emission Tomography (PET).
\n4.1.8 Back treatment programme as a prerequisite for spinal column surgery.
\n4.1.9 The optical benefit is subject to the following clinical rules:
\n4.1.9.1 No single vision prescription < 0.50 dioptre will be paid or considered for payment.
\n4.1.9.2 No bifocal\/varifocal adds for less than 1 dioptre will be paid of considered for payment.
\n4.1.9.3 Bifocal\/varifocal lenses for adults under the age of 40 years old must be motivated.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n35.
\n4.1.9.4 No varifocals for children under the age of 18 years will be paid or considered for
\npayment, with the exception of post-cataract surgery. Bifocals to be considered for
\nchildren under the age of 18 years on motivation only.
\n4.1.9.5 No contact lenses for children under the age of 16 years, unless motivated.
\n4.1.9.6 Motivations are required for composite consultations performed on children under the
\nage of five years old.
\n4.1.9.7 Vertical prism > 1 dioptre should be motivated.
\n4.1.9.8 An additional lens benefit to a maximum of once per 12-month period may, in the sole
\ndiscretion of the contracted service provider, be considered in cases where progressive
\nmyopia can be demonstrated and motivated, and post-cataract surgery, provided in both
\ninstances that the prescription has changed by 0.50 dioptres or more.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n36.
\n5. Applicable co-payments
\n( See PDF Document )<\/p>\n

MEDIHELP RULES: SCHEDULEC
\nBenefit Exclusions with effect from 1 January 2010
\nThe following shall be excluded from benefits, except in the case of statutory prescribed minimum
\nbenefits, subject to the stipulations of rule 8.1:
\n1. General
\n1.1 Services which are not mentioned in the Rules as well as services which in the opinion of the
\nBoard of Trustees, are not aimed at the generally accepted medical treatment of an actual or a
\nsuspected sickness or handicap, which is harmful or threatening to necessary bodily functions
\n(the process of ageing is not considered to be a sickness or handicap).
\n1.2 Travelling and accommodation costs, including meals as well as administration costs of a
\nmember and\/or service provider.
\n1.3 Aptitude and intelligence tests.
\n1.4 Operations, treatments and procedures \u2013
\n1.4.1 of own choice;
\n1.4.2 for cosmetic purposes;
\n1.4.3 for refractive surgery not approved beforehand by Medihelp; and
\n1.4.4 for the treatment of obesity, with the exception of the treatment of obesity which is motivated by
\na medical specialist as life-threatening and approved beforehand by Medihelp.
\n1.5 Treatment of wilfully self-inflicted injuries, unless it is a prescribed minimum benefit.
\n1.6 The treatment of infertility, other than the following treatment (according to PMB code 902M),
\nsubject to pre-authorisation by Medihelp:
\n1.6.1 Hysterosalpinogram.
\n1.6.2 The following blood tests:
\n\u2022 Day 3 FSH \/ LH;
\n\u2022 Oestradiol;
\n\u2022 Thyroid function (TSH);
\n\u2022 Prolactin;
\n\u2022 Rubella;
\n\u2022 HIV;
\n\u2022 VDRL;
\n\u2022 Chlamydia; and
\n\u2022 Day 21 progesterone.
\n1.6.3 Laparoscopy.
\n1.6.4 Hysteroscopy.
\n1.6.5 Surgery (uterus and tubal).
\n1.6.6 Manipulation of ovulation defects and deficiencies.
\n1.6.7 Semen analysis (volume, count, mobility, morphology, MAR-test).
\n1.6.8 Basic counselling and advice on sexual behaviour, temperature charts, etc.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n39.
\n1.6.9 Treatment of local infections.
\n1.7 The artificial insemination of a person as defined in the National Health Act, 2003 (Act No 61 of
\n2003).
\n1.8 Immunisation (including immunisation procedures and material) which is required by an
\nemployer, excluding flu immunisations and standard child immunisations on the Dimension
\nPrime benefit range.
\n1.9 Bandages, cotton wool and plasters on prescription that are not used by a supplier of service
\nduring a treatment\/procedure.
\n1.10 Services which are claimable from the Compensation Commissioner, an employer or any other
\nparty, subject to the stipulations of rule 15.4.
\n1.11 Treatment of alcoholism and drug abuse as well as services rendered by institutions which are
\nregistered in terms of section 21(2) of the Abuse and Dependence-producing Substances
\nand Rehabilitation Centres Act, 1971 (Act No 41 of 1971) or other institutions whose services
\nare of a similar nature, except in the following instance when alcohol and drug abuse will be
\nconsidered as a Prescribed Minimum Benefit:
\nCode Diagnosis Treatment
\n182T
\nAbuse or dependence on
\npsychoactive substance,
\nincluding alcohol
\nHospital based management up to three
\nweeks per benefit year
\n910T
\nAcute delusional mood, anxiety,
\npersonality, perception disorder
\nand organic mental disorder
\ncaused by drugs
\nHospital based management up to three
\nweeks per benefit year
\n910T Alcohol withdrawal delirium;
\nalcohol intoxication delirium
\nHospital based management up to three
\ndays leading to rehabilitation
\n910T Delirium: amphetamine, cocaine,
\nor other psychoactive substance
\nHospital based management up to three
\ndays
\n1.12 Exercise, guidance and rehabilitation programmes.
\n1.13 Treatment of impotence.
\n1.14 Treatment of occupational diseases.
\n1.15 Services rendered by social workers.
\n1.16 Completion of medical and other questionnaires not requested by Medihelp.
\n1.17 Costs for evidence in a lawsuit.
\n1.18 Costs of visits at home and home programmes.
\n1.19 Costs exceeding the guideline tariff for a service or the maximum benefit limit to which a
\nmember is entitled, subject to Annexure 2.
\n1.20 Food substitutes, food supplements and patent food, including baby food.
\n1.21 Multivitamin and multi-mineral supplements alone or in combination with stimulants (tonics).
\n1.22 Slimming remedies, provided that benefits shall be considered if motivated by a medical
\nspecialist as life-essential to be used for a limited period, and if approved beforehand by the
\nPrincipal Officer.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n40.
\n1.23 All patent substances, suntan lotions, anabolic steroids, as well as substances not registered by
\nthe South African Medicines Control Council, except in the case of medicine items approved by
\nMedihelp in the following instances \u2013
\n1.23.1 medicine items with patient-specific exemptions in terms of section 21 of the Medicines and
\nRelated Substances Control Act, 1965 (Act No 101 of 1965) as amended;
\n1.23.2 homeopathic and naturopathic medicine items that have valid NAPPI codes as well as
\ncompounded non-proprietary medicine items dispensed by a homeoparth\/naturopath; and
\n1.23.3 where well-documented, sound evidence-based proof exists of efficacy and cost-effectiveness.
\n1.24 When only accommodation and\/or general care services are rendered.
\n1.25 The cost of transport with an ambulance\/emergency vehicle \u2013
\n1.25.1 from a hospital\/other institution to a residence;
\n1.25.2 in the event of a self-inflicted injury, unless it is a prescribed minimum benefit;
\n1.25.3 in the event of a visit to friends\/family; and
\n1.25.4 to the rooms of a medical practitioner when the objective of the visit\/consultation\/treatment does
\nnot pertain to admission in a hospital.
\n1.26 The cost of harvesting and\/or preserving human tissues, including, but not limited to, stem cells,
\nfor future use thereof to treat a medical condition which has not yet been diagnosed in a
\nbeneficiary.
\n1.27 Dental services:
\n1.27.1 Oral hygiene instructions.
\n1.27.2 Nutritional and tobacco counselling.
\n1.27.3 Caries susceptibility and microbiotical tests.
\n1.27.4 Electrognathographic recordings and other such electronic analyses.
\n1.27.5 Fissure sealants on patients older than 16 years.
\n1.27.6 Root canal treatment on third molars (wisdom teeth) and primary teeth.
\n1.27.7 Pulp capping (direct and indirect).
\n1.27.8 Polishing of restorations.
\n1.27.9 Ozone therapy.
\n1.27.10 Metal base to full dentures, including the laboratory cost.
\n1.27.11 Soft base to new dentures.
\n1.27.12 Diagnostic dentures.
\n1.27.13 Provisional crowns.
\n1.27.14 Laboratory cost of provisional and emergency crowns.
\n1.27.15 Resin bonding for restorations charged as a separate procedure.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n41.
\n1.27.16 Dental bleaching.
\n1.27.17 Porcelain veneers and inlays.
\n1.27.18 Metal, porcelain or resin inlays, except where such inlays form part of a bridge.
\n1.27.19 Crown on third molar (wisdom teeth).
\n1.27.20 Pontics on second molars.
\n1.27.21 Laboratory fabricated crowns on primary teeth.
\n1.27.22 Fixed prosthodontics (crowns) used to repair teeth damaged due to bruxism (tooth grinding),
\ntoothbrush abrasion or attrition, erosion or fluorosis.
\n1.27.23 Perio chip.
\n1.27.24 Apisectomies in hospital.
\n1.27.25 Dentectomies in hospital.
\n1.27.26 Frenectomies in hospital.
\n1.27.27 In-hospital soft tissue impactions.
\n1.27.28 In-hospital single impacted tooth.
\n1.27.29 Conservative dental treatment (fillings, extractions and root canal therapy) in hospital for adults.
\n1.27.30 Professional oral hygiene procedures in hospital.
\n1.27.31 Hospitalisation for dental implantology and surgery related to dental implantology.
\n1.27.32 Hospitalisation for surgical tooth exposure for orthodontic reasons.
\n1.27.33 Orthognathic (jaw correction) surgery and the related hospital cost.
\n1.27.34 Sinus lifts.
\n1.27.35 Bone augmentations.
\n1.27.36 Bone and other tissue regeneration procedures.
\n1.27.37 Gingivectomy.
\n1.27.38 Periodontal flap surgery, tissue grafting and hemisection of a tooth.
\n1.27.39 Orthodontic re-treatment.
\n1.27.40 Lingual orthodontics.
\n1.27.41 Dolder bars and associated abutments on implants (including the laboratory cost).
\n1.27.42 Laboratory costs, where the associated dental treatment is not covered.
\n1.27.43 Laboratory cost associated with mouth guards (including material cost).
\n1.27.44 Snoring appliances.
\n1.27.45 High-impact acrylic.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n42.
\n1.27.46 Cost of mineral trioxide.
\n1.27.47 Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments.
\n1.27.48 Cost of gold, precious metal, semi-precious metal and platinum foil.
\n1.27.49 Cost of invisible retainer material.
\n1.27.50 Cost of bone regeneration material.
\n1.27.51 Replacement of amalgam (silver) fillings with composite (white) fillings.
\n1.27.52 Professionally applied topical fluoride in adults.
\n1.27.53 Laboratory delivery fees.
\n1.27.54 Cost of dental materials in hospital.
\n1.27.55 IV conscious sedation for dental implantology in hospital.
\n1.27.56 Fixed prosthodontics used to restore teeth for cosmetic reasons.
\n1.27.57 Fixed prosthodontics where a reasonable attempt has not been made to restore\/replace the
\ntooth conservatively.
\n1.27.58 Fixed prosthodontics where the patient\u2019s mouth is periodontally compromised.
\n1.27.59 Fixed prosthodontics where the tooth has been recently restored to function.
\n1.27.60 Fixed prosthodontics (crowns) where the tooth is unopposed\/non-functional.
\n1.27.61 Surgical periodontics.
\n1.27.62 Mutliple hospital admissions for the same dental treatment.
\n2. Procedures and medicines excluded from benefits for the Dimension Elite benefit option
\n(Schedule B2), unless it is a prescribed minimum benefit:
\n2.1 Breast augmentation.
\n2.2 Breast reduction.
\n2.3 Gastroplasty.
\n2.4 Sex reversal operations.
\n2.5 Lipectomy.
\n2.6 Epilation.
\n2.7 Otoplasty\/reconstruction of the ear.
\n2.8 Refractive procedures.
\n2.9 Obesity.
\n2.10 All biological and other medicine items as per Medihelp’s medicine exclusion list, unless when
\nindicated and prescribed for the treatment of a PMB condition.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n43.
\n3. Procedures and medicines excluded from benefits for the Dimension Prime benefit
\noptions (Schedule B3, Schedule B4 and Schedule B5), unless it is a prescribed minimum
\nbenefit:
\n3.1 Hip, knee and shoulder replacements
\n3.2 Breast augmentation.
\n3.3 Breast reduction.
\n3.4 Gastroplasty.
\n3.5 Sex reversal operations.
\n3.6 Lipectomy.
\n3.7 Epilation.
\n3.8 Otoplasty\/reconstruction of the ear.
\n3.9 Refractive procedures.
\n3.10 Obesity.
\n3.11 All biological and other medicine items as per Medihelp’s exclusion list, unless when indicated
\nand prescribed for the treatment of a PMB condition.
\n4. Additional to the exclusions listed in paragraph 3 above, the following procedures are
\nalso excluded from benefits for the Dimension Prime 1 benefit option (Schedule B5):
\n4.1 Hymenectomy.
\n4.2 Circumcision.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n44.
\nMEDIHELP RULES: SCHEDULE C.1
\nBenefit Exclusions with effect from 1 January 2010
\nfor the Necesse benefit option
\nThe following shall be excluded from benefits, except in the case of statutory prescribed minimum
\nbenefits, subject to the stipulations of rule 8.1:
\n1. General
\n1.1 Services which are not mentioned in the Rules as well as services which in the opinion of the
\nBoard of Trustees, are not aimed at the generally accepted medical treatment of an actual or a
\nsuspected sickness or handicap, which is harmful or threatening to necessary bodily functions
\n(the process of ageing is not considered to be a sickness or handicap).
\n1.2 Healthcare services required during a compulsory waiting period, as underwritten by the
\nScheme.
\n1.3 Travelling and accommodation costs, including meals as well as administration costs of a
\nmember and\/or service provider.
\n1.4 Aptitude and intelligence tests.
\n1.5 Operations, treatments and procedures \u2013
\n1.5.1 of own choice;
\n1.5.2 for cosmetic purposes;
\n1.5.3 for refractive surgery not approved beforehand by Prime Cure; and
\n1.5.4 for the treatment of obesity, with the exception of the treatment of obesity which is motivated by
\na medical specialist as life-threatening and approved beforehand by Prime Cure.
\n1.6 All slimming remedies and preparations to treat obesity.
\n1.7 Contact lenses and contact lens solutions.
\n1.8 Food substitutes and supplements, including baby food and special milk preparations.
\n1.9 Homeopathic and herbal medicine, as well as household remedies or any other miscellaneous
\nhousehold product of a medicinal nature.
\n1.10 Medicine for the treatment of alcoholism and dependence-forming substances, unless it is a
\nprescribed minimum benefit.
\n1.11 Anabolic steroids.
\n1.12 Roaccutane and Retin A, or any skin lightening agents.
\n1.13 Wilfully self-inflicted injuries and illnesses, unless it is a prescribed minimum benefit.
\n1.14 Recuperative treatment of any nature.
\n1.15 Injuries sustained during participation in a strike, unlawful demonstration, unrest or violent
\nconduct, except in the case of a prescribed minimum benefit.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n45.
\n1.16 Services rendered to beneficiaries outside the Prime Cure network, except for those services as
\nlisted in Schedule B6 or if voluntarily obtained from a non-designated service provider in the
\ncase of a PMB condition.
\n1.17 Stimulant laxatives, unless pre-authorised.
\n1.18 The cost of reports, examinations and tests for insurance policies and for legal reasons.
\n1.19 Acupuncture, biokinetic, chiropractic, herbalist, naturopathic and homeopathic services.
\n1.20 Back and neck fusion, unless it is a prescribed minimum benefit.
\n1.21 Joint replacement, unless it is a prescribed minimum benefit.
\n1.22 The artificial insemination of a person as defined in the National Health Act, 2003 (Act No 61 of
\n2003).
\n1.23 Immunisation (including immunisation procedures and material) which is required by an
\nemployer, excluding flu immunisations.
\n1.24 Bandages, cotton wool and plasters on prescription that are not used by a supplier of service
\nduring a treatment\/procedure.
\n1.25 Services which are claimable from the Compensation Commissioner, an employer or any other
\nparty, subject to the stipulations of rule 15.4.
\n1.26 Treatment of alcoholism and drug abuse as well as services rendered by institutions which are
\nregistered in terms of section 21(2) of the Abuse and Dependence-producing Substances
\nand Rehabilitation Centres Act, 1971 (Act No 41 of 1971) or other institutions whose services
\nare of a similar nature, except if alcohol and drug abuse will be considered as a Prescribed
\nMinimum Benefit.
\n1.27 Exercise, guidance and rehabilitation programmes.
\n1.28 Treatment of impotence.
\n1.29 Treatment of occupational diseases, unless a PMB.
\n1.30 Services rendered by social workers.
\n1.31 Completion of medical and other questionnaires not requested by Medihelp.
\n1.32 Costs for evidence in a lawsuit.
\n1.33 Costs exceeding the guideline tariff for a service or the maximum benefit limit to which a
\nmember is entitled, subject to Annexure 2.
\n1.34 Multivitamin and multi-mineral supplements alone or in combination with stimulants (tonics),
\nunless a PMB.
\n1.35 All patent substances, suntan lotions, anabolic steroids, as well as substances not registered by
\nthe South African Medicines Control Council, except in the case of medicine items approved by
\nPrime Cure in the following instances \u2013
\n1.35.1 medicine items with patient-specific exemptions in terms of section 21 of the Medicines and
\nRelated Substances Control Act, 1965 (Act No 101 of 1965) as amended; and
\n1.35.2 where well-documented, sound evidence-based proof exists of efficacy and cost-effectiveness.
\n1.36 When only accommodation and\/or general care services are rendered (frail care).
\nRules as registered by the Registrar \u2013 Version 4.2010
\n46.
\n1.37 The cost of transport with an ambulance\/emergency vehicle to the rooms of a medical
\npractitioner when not medically required and when the objective of the
\nvisit\/consultation\/treatment does not pertain to admission in a hospital
\n1.38 The cost of harvesting and\/or preserving human tissues, including, but not limited to, stem cells,
\nfor future use thereof to treat a medical condition which has not yet been diagnosed in a
\nbeneficiary.
\n1.39 All biological and other medicine items as per Medihelp’s exclusions list, unless when indicated
\nand prescribed for the treatment of a PMB condition.
\n1.40 Dental services:
\n1.40.1 Dental extractions for non-medical reasons.
\n1.40.2 Provision for gold inlays in dentures.
\n1.40.3 Oral hygiene instructions.
\n1.40.4 Nutritional and tobacco counselling.
\n1.40.5 Caries susceptibility and microbiological tests.
\n1.40.6 Electrognathographic recordings and other such electronic analyses.
\n1.40.7 Fissure sealants on patients older than 16 years.
\n1.40.8 Root canal treatment, crowns, bridges and other advanced or specialised dentistry.
\n1.40.9 Root canal treatment on third molars (wisdom teeth) and primary teeth.
\n1.40.10 Pulp capping (direct and indirect).
\n1.40.11 Polishing of restorations.
\n1.40.12 Fluoride treatment of patients 12 years and older, unless pre-authorised.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n47.
\nMEDIHELP RULES: SCHEDULE C.2
\nBenefit Exclusions with effect from 1 January 2010
\nfor the Unify benefit option
\nThe following, together with the exclusions listed in Schedule C, shall be excluded from benefits, except in
\nthe case of statutory prescribed minimum benefits, subject to the stipulations of rule 8.1:
\n1. General
\n1.1 The cost for hiring and purchasing medical, surgical, orthopaedic and other appliances,
\nincluding surgical stockings.
\n1.2 The treatment of acne and skin conditions.
\n1.3 Patent medicine, beauty preparations, bandages, cotton wool and similar material, patent foods
\nincluding baby food, contraceptives and apparatus to prevent pregnancies, tonics, slimming
\npreparations, household and biochemical remedies, contact lens solutions, homeopathic
\nmedicine, vitamins, and any drug or remedies not registered with the SA Medicines Control
\nCouncil or similar institution.
\n1.4 All costs related to the treatment of sickness conditions that were specifically excluded from
\nbenefits when the beneficiaries joined the Scheme as per the waiting periods.
\n1.5 The cost of medicine purchased from a person not legally entitled to supply or prescribe
\nmedicine.
\n1.6 Any expenses incurred by a beneficiary in respect of general practitioner services, procedures
\nand dispensed medicine other than those services provided by the beneficiary\u2019s selected
\ngeneral practitioner, and other than the out-of-area benefits, subject to Annexure 2.
\n1.7 Any expenses incurred by a beneficiary in respect of optical and dental services, other than the
\nservices provided by the beneficiary\u2019s selected optometrist\/dentist.
\n1.8 The cost of any services rendered by a specialist without recommendation and\/or referral of the
\nbeneficiary\u2019s selected general practitioner, subject to Annexure 2.
\n1.9 Appointments cancelled and\/or not kept.
\n1.10 The cost involved in any surgical procedure, treatment, equipment, agent or medicine of
\nexperimental nature.
\n1.11 The treatment of snoring, rhinoplasty, mammoplasty or uvulopalatopharyngioplasty.
\n1.12 Immunisations normally available from State facilities and anti-malaria agents used as
\nprophylaxis against malaria.
\n1.13 Injuries sustained during participation in a strike, unlawful action, revolt or violent behaviour.
\n1.14 All biological and other medicine items as per Medihelp’s exclusion list, unless when indicated
\nand prescribed for the treatment of a PMB condition.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n48.
\nMEDIHELP RULES: SCHEDULED
\nEmergency Transport Services and Transport of Blood and Medicine
\n1. Scope of services
\n1.1 As from 1 January 2010 beneficiaries are entitled to the following benefits for services rendered
\nby Netcare 911, subject to the benefit exclusions stated in paragraph 3 of this Schedule.
\n1.1.1 Emergency medical assistance during emergency transport or relocation
\nMedihelp Plus, Dimension Elite and Dimension Prime benefit options:
\n1.1.1.1 The transport of a beneficiary, being a resident of South Africa, Swaziland, Lesotho, Namibia
\nand Mozambique, to the nearest, most appropriate medical facility equipped for the patient\u2019s
\nspecific emergency medical condition, if recommended and authorised by the staff of Netcare
\n911: provided that the emergency occurs within the beneficiary\u2019s land of residence.
\n1.1.1.2 In case of the emergency occurring outside the borders of the beneficiary\u2019s land of residence,
\nthe limit for transport outside the borders, as per Schedules B1, B2, B3, B4 and B5, will apply.
\nUnify benefit option:
\n1.1.1.3 The transport of a beneficiary, being a resident of South Africa, to the nearest, most appropriate
\nmedical facility equipped for the patient\u2019s specific emergency medical condition, if
\nrecommended and authorised by the staff of Netcare 911: provided that the emergency occurs
\nwithin the borders of South Africa.
\n1.1.1.4 No benefits for emergency transport outside the borders of South Africa.
\nNecesse benefit option:
\n1.1.1.5 The transport of a beneficiary, being a resident of South Africa, to the nearest, most appropriate
\nfacility equipped for the beneficiary\u2019s non-life-threatening emergency medical condition, if
\nrecommended and authorised by the staff of Netcare 911: provided that the emergency occurs
\nwithin the borders of South Africa.
\n1.1.1.6 No benefits for emergency transport outside the borders of South Africa.
\n1.1.2 Emergency transport of medicine and\/or blood
\n1.1.2.1 In the event that blood and\/or medicine required for the treatment of a beneficiary in a lifethreatening
\nemergency medical condition are not available locally, Netcare 911 shall transport
\nthese items to the appropriate facility.
\n2. Procedure to be followed in order to qualify for benefits
\n2.1 In the event of an emergency medical condition the following measures shall be applicable:
\n2.1.1 Any beneficiary who requires emergency medical assistance must phone the Netcare 911
\ncontact centre so that the nature of the medical assistance required can be determined and the
\nmember can be transported to the nearest appropriate medical facility, if necessary.
\n2.1.2 Should the emergency medical condition be of such a nature that the member is not able to
\ncontact the Netcare 911 contact centre or request emergency transport personally, the
\ndependant of the member, his spouse or other representative must notify the Netcare 911
\ncontact centre within twenty-four (24) hours after an incident occurred.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n49.
\n2.1.3 In the event that the Netcare 911 contact centre is not notified of the incident as stipulated
\nabove and the necessary approval is not granted, Netcare 911 reserves the right to refuse
\npayment to a third party in respect of the rendering of emergency services.
\n2.1.4 In the event of an incident that is not life-threatening (non-emergency) the member shall be
\nliable for payment of the account if the necessity for emergency medical transport has not been
\nconfirmed by Netcare 911.
\n3. Services that do not qualify for benefits
\n3.1 Netcare 911 shall not be responsible for rendering any assistance to the beneficiary in
\ncircumstances where the emergency medical condition \u2013
\n3.1.1 is not reported to the Netcare 911 contact centre by the beneficiary or a representative on his
\nbehalf unless the circumstances of the emergency medical condition dictate otherwise, in which
\ncase authorisation must be obtained within twenty-four (24) hours after the incident;
\n3.1.2 is of such nature that, in the opinion of the medical staff appointed by Netcare 911, no medical
\nassistance and\/or transport is justified;
\n3.1.3 occurs after the expiry of the beneficiary\u2019s membership;
\n3.1.4 occurs in periods when the beneficiary\u2019s benefits have been suspended; and
\n3.1.5 is related to the benefit exclusions as listed in paragraph 1.25 of Schedule C.
\n4. General stipulations
\n4.1 Neither Netcare 911 nor Medihelp shall be liable for the payment of interest owing as a result of
\nthe non-payment of a claim that cannot be ascribed to Netcare 911 or Medihelp.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n50.
\nMEDIHELP RULES: SCHEDULE E
\nProcedure applicable during voting at a general meeting
\n1. Voting takes place for the period as determined by the chairman in consultation with the
\nmeeting.
\n2. Voting on every item on the agenda that must be voted on shall take place by means of a vote
\nby ballot cast by those members who are present at the meeting as well as votes cast by proxy
\nby warrantors. A ballot paper shall only be issued to a person who is present at a meeting and
\nwho can provide proof of membership of Medihelp and whose subscriptions are paid up.
\n3. The chairman, in consultation with the meeting, appoints a chief scrutineer and scrutineers
\nresponsible for collecting ballot papers and counting votes.
\n4. The officials who issue ballot papers, shall record the number of ballot papers issued and shall
\nreport this number to the chief scrutineer before voting commences.
\n5. Once the chief scrutineer has indicated to the chairman that all members who are entitled to
\nvote have received ballot papers, the chairman shall declare that ballot papers shall no longer
\nbe issued, that no person who acts as a proxy shall legally represent any proxy vote if such
\nperson is not present at that time, and that voting will commence:
\n5.1 A member\/proxy places his ballot paper(s) on which he has indicated his choice(s) in a sealed
\nballot box.
\n5.2 Persons who have elected not to cast a vote, are also required to place their ballot papers in the
\nsealed ballot box.
\n5.3 No ballot papers may be placed in the ballot box after expiry of the voting period, and the
\nmeeting shall continue with proceedings.
\n6. The procedure regarding the counting of votes shall take place as follows:
\n6.1 The chief scrutineer opens the ballot box in the presence of all the scrutineers.
\n6.2 The chief scrutineer shall ascertain whether the number of ballot papers in the ballot box
\ncorresponds with the number of ballot papers issued. Should the number of ballot papers in the
\nballot box not correspond with the number of ballot papers issued, the election is invalid and
\nmust be held again: provided that the general meeting may, by means of a majority of votes of
\nmembers who are present in person, condone the disparity in the number of ballot papers if
\nsuch disparity does not influence the results of the election.
\n6.3 Votes are counted and as soon as a result has been obtained, the chief scrutineer must hand a
\ncertificate to the chairman which contains the following:
\n6.3.1 The number of ballot papers issued and that such number corresponds with that in the ballot
\nbox.
\n6.3.2 The number of valid proxy votes.
\n6.3.3 In the case of the election of members of the Board of Trustees, the number of votes obtained
\nby each candidate, and in the case of all other matters voted on, the results of voting, including
\nthe number of votes in favour of, against, abstained from and spoilt.
\n6.3.4 The number of spoilt votes and spoilt proxy votes.
\n6.3.5 A declaration that voting was conducted in accordance with the prescribed procedure.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n51.
\nMEDIHELP RULES: ANNEXURE 1
\nPersonal Medical Savings Account
\n1. The monthly savings account contributions for the various benefit options are as set out in
\nSchedule A.
\n2. A credit facility, equalling the applicable monthly contribution to the personal medical savings
\naccount multiplied by twelve (12), shall be made available to a member at the beginning of each
\nfinancial year. The credit facility shall be recalculated at the beginning of each month by
\nmultiplying the applicable monthly contribution to the personal medical savings account by the
\nremaining number of months until the end of the financial year. Should a member be enrolled
\nduring the course of a financial year, the credit facility will be prorated according to the
\nremaining number of months of the financial year.
\n3. The funds in the savings account, including the credit facility, shall be used to \u2013
\n3.1 pay for medical expenses which are payable from the savings account, as contemplated in
\nSchedule B, and
\n3.2 pay expenses exceeding the applicable tariff, levies and member co-payments,
\nprovided that all accounts to be paid from the savings accounts shall be submitted to Medihelp
\nwithin the prescribed submission period.
\n4. The funds in the personal medical savings account shall not be used to pay for the cost of
\nprescribed minimum benefits or any co-payment in respect thereof or to pay for subscriptions.
\n5. In the event of a member who \u2013
\n5.1 interchanges to another medical scheme or transfers to another benefit option of Medihelp, the
\nfunds in the savings account shall \u2013
\n5.1.1 be transferred to the member\u2019s personal medical savings account at the other medical scheme
\nor benefit option within four (4) calendar months after termination of membership of Medihelp; or
\n5.1.2 be refunded to the member within four (4) calendar months after termination of his membership
\nof Medihelp or after such transfer, subject to applicable laws, if the other scheme or option does
\nnot provide for a personal medical savings account;
\n5.2 terminates his membership and is not admitted as a member of another medical scheme, the
\nfunds in the savings account shall be refunded to the member within four (4) calendar months
\nafter termination of membership of Medihelp, subject to applicable laws; or
\n5.3 dies, the funds in the savings account shall be transferred to the savings account of his
\ndependants who qualify for continued membership, and should he not have any such
\ndependants, the funds in the savings account shall be paid to his estate, subject to applicable
\nlaws.
\n6. Notwithstanding the stipulations of paragraph 5, the funds in the savings account shall be used
\nto offset any debt owed by the member to Medihelp on termination of membership and a debit
\nbalance shall be payable to Medihelp immediately.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n52.
\nMEDIHELP RULES: ANNEXURE 2
\nPrescribed Minimum Benefits
\n1. General
\n1.1 Subject to the stipulations of rule 8.1, benefits regarding a prescribed minimum benefit condition
\nshall be paid from the relevant benefit category as set out in Schedules B1 to B7, provided that
\nMedihelp shall grant benefits in terms of the conditions contemplated in this Annexure at 100%
\nof the cost, without limits or co-payments, in respect of the diagnosis, treatment and care costs
\nof \u2013
\n1.1.1 the prescribed minimum benefit conditions as listed in Schedule A to the Regulations; and
\n1.1.2 an emergency medical condition.
\n1.2 In the case of chronic conditions regarding prescribed minimum benefits, benefits shall be
\nlimited to the scope of the therapeutic algorithms as determined by the Medical Schemes Act
\nand chronic conditions in the treatment pairs of PMB.
\n2. Pre-registration
\n2.1. In order to qualify for prescribed minimum benefits, the prescribed minimum benefit condition as
\nwell as each separate service relating to the condition must be pre-registered in the manner as
\nprescribed by Medihelp: provided that \u2013
\n2.1.1 in the event of the diagnosis not being confirmed prior to the service rendering, the service must
\nbe registered within forty-eight (48) hours after the service has been rendered, or on the first
\nworking day thereafter should the registration period fall over a weekend or public holiday;
\n2.1.2 a psychiatric admission shall be regarded as a prescribed minimum benefit condition during the
\npre-registration of the admission; and
\n2.1.3 in the case of an emergency medical condition, registration must take place on the subsequent
\nday of business after the incident.
\n2.2. Registration shall be subject to Medihelp\u2019s protocols, including the applicable medicine
\nformularies, which apply to the treatment of the prescribed minimum benefit condition.
\n2.3 Should the prescribed minimum benefit condition as well as each separate service relating to
\nthe condition not be registered with Medihelp in the manner set out in paragraph 2.1, benefits
\nshall be granted subject to the applicable tariffs\/member co-payments\/levies\/annual limits and
\nother conditions as stipulated in Schedule B1 to B7.
\n3. Designated service provider
\n3.1 Where applicable, the prescribed minimum benefit services and\/or prescribed medicine must be
\nobtained from a designated service provider. Details of the designated service providers, which
\ninclude all Government hospitals, are available from Medihelp.
\n3.2 If a beneficiary voluntarily obtains services and\/or prescription medicine from a non-designated
\nservice provider, the co-payments as set out in paragraph 7.1 shall apply.
\n3.3 If a beneficiary involuntarily obtains services and\/or prescription medicine from a nondesignated
\nservice provider, the stipulations of paragraph 7.1 shall not apply if \u2013
\n3.3.1 the service was not available from the designated service provider or would not be provided
\nwithout unreasonable delay;
\nRules as registered by the Registrar \u2013 Version 4.2010
\n53.
\n3.3.2 immediate medical or surgical treatment for a prescribed minimum benefit condition was
\nrequired under circumstances or at locations which reasonably precluded the beneficiary from
\nobtaining such treatment from a designated service provider; or
\n3.3.3 there was no designated service provider within reasonable proximity to the beneficiary\u2019s
\nordinary place of business or personal residence.
\n3.4 Except in the case of an emergency medical condition, pre-authorisation must be obtained from
\nMedihelp if the member involuntarily obtains the services from a provider other than a
\ndesignated service provider in terms of paragraph 7.1, to enable Medihelp to confirm that the
\ncircumstances as contemplated are applicable.
\n4. Medicine
\n4.1 If medicine is dispensed and the beneficiary opts to use medicine which costs more than the
\napplicable Medihelp Reference Price, the member will be liable to pay the difference between
\nthe cost of the medicine dispensed and the reference price used to determine the benefit
\namount.
\n4.2 The stipulations of paragraph 4.1 shall not apply in cases where a beneficiary has to use
\nmedicine which costs more than the Medihelp Reference Price for clinically appropriate
\nreasons, as motivated by the member\u2019s attending physician, provided that pre-authorisation is
\nobtained from Medihelp.
\n5. Diagnostic services for unconfirmed prescribed minimum benefit conditions
\n5.1 Where diagnostic tests do not result in confirmation of a prescribed minimum benefit condition,
\nexcept for an emergency medical condition, such diagnostic tests shall not be considered as
\nprescribed minimum benefits.
\n6. Protocols
\n6.1 If a beneficiary voluntarily obtains services and\/or prescription medicine which deviates from the
\napplicable protocols, the co-payments as set out in paragraph 7.2 shall apply.
\nRules as registered by the Registrar \u2013 Version 4.2010
\n54.
\n7. Applicable co-payments
\n(See PDF document )<\/p>\n","protected":false},"excerpt":{"rendered":"

Rules as registered by the Registrar \u2013 Version 4.2010 1. RULES OF MEDIHELP (As registered in English) 1. Name of the Medical Scheme The name of the medical scheme is \u201cMedihelp\u201d. 2. Legal Persona Medihelp may, in its own name, sue and be sued, purchase or otherwise acquire, hold, mortgage, let and alienate property, movable […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":740,"menu_order":5,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"_links":{"self":[{"href":"https:\/\/profconsure.co.za\/index.php?rest_route=\/wp\/v2\/pages\/750"}],"collection":[{"href":"https:\/\/profconsure.co.za\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/profconsure.co.za\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/profconsure.co.za\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/profconsure.co.za\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=750"}],"version-history":[{"count":8,"href":"https:\/\/profconsure.co.za\/index.php?rest_route=\/wp\/v2\/pages\/750\/revisions"}],"predecessor-version":[{"id":4496,"href":"https:\/\/profconsure.co.za\/index.php?rest_route=\/wp\/v2\/pages\/750\/revisions\/4496"}],"up":[{"embeddable":true,"href":"https:\/\/profconsure.co.za\/index.php?rest_route=\/wp\/v2\/pages\/740"}],"wp:attachment":[{"href":"https:\/\/profconsure.co.za\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=750"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}