Essential

Hospital Cover for when you need it most

Medical cover is essential in times of unexpected medical emergencies. Ensure that you and your family are covered for emergency hospital visits.

What's Covered

Pre-authorisation (PAR) is required in respect of hospitalisation and the associated clinical procedures before treatment starts or, in case of an emergency, within the next two business days, otherwise no benefits are allowed.

Click here for help understanding our terminology.

Access the Topmed Formulary for this plan here.

Click here to download the 2019 Essential Benefit Guide.

Hospitalisation
  • Hospital CoverUnlimited Private Hospital Cover. Designated Service Provider Hospital – 100% of Agreed Tariff. Non-Designated Service Provider Hospital – 75% of Agreed Tariff
  • Casualty Cover (Treatment delivered on day of injury – Trauma only) 100% of Topmed Tariff . 100% of Agreed Tariff for facility fee
  • Neo-natal confinement Unlimited
  • Elective Caesarean 100% of Topmed Tariff
  • Home Birth / Water Birth Subject to a registered service provider assisting with the birth
  • Ambulance Services 100% of Agreed Tariff at preferred provider. 100% of Topmed Tariff limited to R2 328 per family per annum for non-preferred provider
  • Specialised Surgery (New technology) No benefit
  • Psychiatric admissions Case Managed and limited to 21 days per beneficiary per annum
  • Immunocompromise and Opportunistic Infections 100% of Topmed Tariff . Limited to R46 872 per family per annum
  • TTO Medication (Received on discharge) 100% of Agreed Tariff. Max 7 days supply (Topmed Reference Price and formulary applies)
  • Medical Practitioners and Specialists 100% of Topmed Tariff . Prescribed Minimum Benefits - Designated Service Provider applies
  • Secondary Facilities (Step-down nursing, hospice and rehabilitation) Case Managed and limited to R139 200 per beneficiary per annum
  • Dentistry No benefit
  • Maxillo-Facial Surgery 100% of Topmed Tariff subject to clinical criteria and limited to jaw fractures, congenital deformaties and pathological conditions
  • Impacted Wisdom Teeth No benefit
  • Orthognathic Surgery No benefit
  • Scopes (Gastroscopies and Colonoscopies) (Pre-authorisation required) 100% of Topmed Tariff subject to a R2 600 co-payment per scope. If performed in a day clinic/doctors rooms no co-payment applies
Radiology and Pathology during hospitalisation
  • Radiology and Pathology 100% of Topmed Tariff
  • MRI scans, CT scans, radioisotope studies (Pre-authorisation required) 100% of Topmed Tariff subject to a R2 600 co-payment per scan
Auxillary Services during hospitalisation
  • Blood transfusions 100% of Cost
  • Physiotherapy, speech therapy, occupational therapy, social workers and dieticians 100% of Topmed Tariff
  • Clinical and medical technologists 100% of Topmed Tariff
  • Internal medical and surgical accessories (additional Pre-authorisation required) 100% of Cost subject to sub-limits as applied per clinical protocols.

This is a hospital plan only therefore no benefits are provided for day-to-day claims (unless you are registered on a specific chronic or disease management programme).

Day to Day Benefits – Out of Hospital
  • Casualty Cover (Non Trauma) No benefit
  • Medical Practitioners and Specialists – Including clinical procedures, visits (Prescribed Minimum Benefits - Designated Service Provider applies), material and injection material (excluding medicine) administered in a Doctor’s consulting room No benefit
  • Prescribed Acute Medication No benefit
  • Reproductive Health – Oral, injectable and IUD contraceptives No benefit
  • Vitamins and Minerals No benefit
  • OTC Medication No benefit
  • Optical No benefit
  • Dentistry (Conservative and Specialised) No benefit
  • Clinical Psychology and Psychiatric Treatment No benefit
Radiology and Pathology – Out of Hospital
  • Basic radiology No benefit
  • MRI scans, CT scans, radioisotope studies (Pre-authorisation required) Limited to Prescribed Minimum Benefits
  • Basic pathology No benefit
Auxillary Services – Out of Hospital
  • Physiotherapy, speech therapy, occupational therapy, social workers, dieticians, podiatry,orthoptic treatment, audiometry, hearing aid acoustics, biokinetics, chiropractors, osteopaths, homeopaths, naturopaths and herbalists No benefit
  • Clinical and Medical Technologists No benefit
  • External medical and surgical appliances (Pre-authorisation required) No benefit
Chronic Medication (Registration required)
  • Unlimited Chronic Conditions 100% of Agreed Tariff – Designated Service Provider applies. Prescribed Minimum Benefit. Topmed Reference Price and formulary applies. Click here for the Topmed Formulary.
  • Prescribed Minimum Benefits / Non-Formulary / Non-Designated Service Providers 70% of Agreed Tariff
Disease Management Programmes (Registration required)
  • HIV / AIDS Case Managed and limited to Prescribed Minimum Benefits
  • Organ Transplant Case Managed and limited to Prescribed Minimum Benefits
  • Kidney Dialysis Case Managed and limited to Prescribed Minimum Benefits
  • Oncology Case Managed and limited to R298 320 pb per 12 month cycle
  • Oncology Speciality Medicines and Biologicals No benefit
  • Stomatherapy Limited to Prescribed Minimum Benefits
TopBaby Maternity Programme (Registration required)
  • Antenatal Consultations (Tariff code 0190 / 0192) 100% of Topmed Tariff limited to 3 consultations
  • Antenatal Classes (Tariff code 88407) 100% of Topmed Tariff limited to 12 classes
  • Antenatal Scans (3D and 4D scans paid at 2D rate) Limited to 1 2D scan per beneficiary per pregnancy
  • Paediatrician Consultations Limited to 1 newborn visit
  • Prenatal Vitamins Formulary applies
  • Baby Bag Yes
  • Baby Immunisations (Subject to Department of Health Protocols)
Wellness Benefits
  • Screening Benefits (Health Assessment) yes
  • Immunisation Programme yes
  • Early Detection Tests yes
Extended Benefits (Pre-authorisation required)
  • Post total hip replacement Trauma only
  • Post total knee replacement Trauma only
  • Post crime trauma Combined total of 12 consultations within 6 months post-event with a Psychologist, Psychiatrist or Social Worker
  • Heart Attack Case Managed. Treatment must be prescribed by the treating Cardiologist/ Physician
  • Stroke Case Managed. Comprehensive rehabilitation programme including therapy from a multi-disciplinary team 3 months post-event (acute) with a Physiotherapist, Occupational Therapist and Speech Therapist
Deductibles and Co-Payments
  • Kindly refer to Benefit Guide for specific deductibles and co-payments. Scheme policies and protocols apply
Prosthesis Benefits
  • Kindly refer to Benefit Guide for specific internal medical/surgical prostheses and appliance limits. Scheme policies and protocols apply
International Business and Leisure Travel Insurance
  • Foreign claims are limited to medical expenses only as provided by the Schemes’s policy, limited to R10 million per family per year, subject to authorisation and applicable conditions. Maximum of 90 days cover, travel must be declared before departure
Essential Principal member Adult dependant Student / minor dependant
Contribution R1 588 R1 278 R645
Savings Level N/A N/A N/A
Total R1 588 R1 278 R645

The Scheme only charges for a maximum of 3 children on this option.



Need help choosing?

Find out which option is best for you with our online option selector.

Learn more

Got a question? Get in touch

Our Wellness Nurses are qualified to help you make the lifestyle choices you need to improve your health

Email us

Ready to apply? It’s easy online

Our Wellness Nurses are qualified to help you make the lifestyle choices you need to improve your health

Apply now