Your Discovery Health Plan Guide

Essential Saver Plan

Message from Discovery Health

Thank you for giving us the opportunity to look after your healthcare cover needs. You can have peace of mind that Discovery Health places our members first with a focus on comprehensive benefits, value for money and services to improve the quality of care available to our members. Our substantial scheme reserves give you complete confidence that your medical scheme will be able to pay your claims not just today but over the long term. The Scheme enjoys an AA+ rating for its claims paying ability from independent rating agency, Global Credit Ratings. This is the highest rating a medical scheme can achieve and reflects the schemes sound financial position and the security we provide to you. We are proud that all Discovery Health members have access to the broadest and best level of healthcare cover available in the market. In addition to excellent benefits, Discovery Health continues to invest heavily in our people and technology to ensure that we deliver world-class service to our members, through our call centres and walk-in centres around the country, and through our deployment of well-trained Discovery staff to assist our members when in hospital or facing difficult diagnoses, such as cancer. In an effort to further increase value and improve the quality of care and service convenience for our members, Discovery Health will continue to expand the services we will offer members in 2012. Our Discovery MedXpress service is now operational nationally for the delivery of chronic medicines to your home or workplace, and we will extend this service to all other prescription medicines during the course of 2012. Another innovation on this front is MedSaver, which brings you substantial savings of up to 25% on schedule 1 and 2 medicines. MedSaver is offered in partnership with Clicks and will be available in all Clicks stores from 2012. We have designed this guide to provide you with a summary of information on how to get the most out of your Discovery Health Plan. Youll find the Full Cover Choice stamp throughout the guide. It shows you when to use our range of online tools that help you choose full cover options for hospitalisation, specialists in hospital, chronic medicine and GP consultations. We are here to help and guide you in making the best choices when it comes to your healthcare. We look forward to looking after you and your family in 2012.

Discovery Health provides you with all the tools you need to know about your health plan and how to make the most of your cover.

Our scheme rules are available on our website This brochure is a summary of the benefits and features of your Discovery Health Medical Scheme Plan, pending formal approval from the Council for Medical Schemes. The rules of the Discovery Health Medical Scheme apply to your benefits. If you want to refer to the full set of scheme rules on which this brochure is based, please email compliance@discovery.co.za or go to www.discovery.co.za The rules and benefits explained in this guide apply to the main member and the dependants registered on their scheme membership.

Kind regards

Dr Jonathan Broomberg CEO: Discovery Health

Milton Streak Principal Officer: Discovery Health Medical Scheme

Contents
Summary of benefits .........................................................................................................................1 Cover for medical emergencies ..........................................................................................................2 Hospital Benefits ...............................................................................................................................3 Cover for chronic conditions and oncology .........................................................................................7 Out-of-hospital cover .........................................................................................................................8 General exclusions ...........................................................................................................................10 Important tips when claiming ..........................................................................................................10

Summary of benefits

The Hospital Benefit covers you if you are admitted to hospital and Discovery Health has confirmed your admission and treatment before you are admitted. You have cover for a list of chronic conditions and cover for cancer, HIV and AIDS. Your health benefits include cover for medical expenses while travelling in other countries. We pay your day-to-day expenses from the available money in your Medical Savings Account. We extend your day-to-day cover by paying for GP consultations through the Insured Network Benefit.

If you want to change your plan You can change to any other plan at the end of each year with effect from 1 January the following year, but not during the year. If you need advice on the appropriate Plan choice, please speak to your financial adviser before you decide to change your plan. Detailed explanations of our benefits are available on www.discovery.co.za or you can contact us.

Make the Full Cover Choice We offer you the choice to be covered in full for hospitalisation, specialists in hospital and chronic medicine. Look out for the Full Cover Choice stamp in this brochure. It shows you when to use our range of online tools that help guide you to full cover.

According to the Prescribed Minimum Benefits, you have the right to a guaranteed level of cover for a list of medical conditions and treatments even if your health plans benefits have run out. These benefits include cover for a list of 270 listed conditions, most emergency conditions and 27 listed chronic conditions, including HIV and AIDS. Medical schemes must provide cover for the diagnosis, treatment and cost of ongoing care for these conditions according to the Schemes rules and guidelines. In most cases, Discovery Health plans offer benefits which are far richer than the Prescribed Minimum Benefits. To find out how you can access Prescribed Minimum Benefits, go to www.discovery.co.za or contact us for more information.

make sure you understand the benefits you have on the plan you chose

The benefits explained in this brochure are provided by the Discovery Health Medical Scheme, registration number 1125, administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised financial services provider. In this document we refer to Discovery Health Medical Scheme (Pty) Ltd as Discovery Health.

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Cover for medical emergencies

What is a medical emergency?
A medical emergency is the sudden and, at the time, unexpected onset of a health condition that needs immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the persons life in serious jeopardy in line with the Schemes rules.

If you go to a casualty or emergency room and you are not admitted to hospital, we will pay the costs from your available day-to-day benefits. Some casualties charge a facility fee, which we do not cover.

Cover for evacuation in Africa

The Africa Evacuation Benefit covers you for emergency medical evacuations from certain sub-Saharan African countries back to South Africa. You can find the list of African countries this benefit covers and the details of the cover before travelling on www.discovery.co.za. When you have a medical emergency All emergency treatments outside the borders of South Africa must be confirmed by calling International SOS on +27 11 541 1222. This number is displayed on your membership card.

Cover under the Prescribed Minimum Benefits

In an emergency, when your normal plan cover does not apply, for example you are in a waiting period, we will cover you in full in any hospital until you have been stabilised. If you are not being treated at a network provider, you may be transferred to a network provider once you are stable to ensure you have full cover. If you choose to be treated by a non-network provider, we will cover you up to 80% of the Discovery Health Rate in line with the Schemes rules. There may be instances when you do not have Prescribed Minimum Benefit cover, like when you are in a waiting period or when you join a medical scheme for the first time, with no previous medical scheme membership. This can also happen if someone joins a medical scheme more than 90 days after leaving his or her previous medical scheme.

Cover for medical emergencies in South Africa

Cover for going to hospital In an emergency, go straight to hospital. If you need medically equipped transport, call 0860 999 911. This line is managed by highly qualified emergency personnel who will send air or road emergency evacuation transport to you, depending on which is most appropriate. It is important that you, a loved one or the hospital let us know about your admission as soon as possible.

Cover while travelling overseas

The International Travel Benefit provides cover of up to R5 million for each person on each journey for emergency medical costs while you travel outside South Africa. This cover is for a period of 90 days from your departure from South Africa. Cover includes appropriate emergency evacuation and transport if needed. You pay the first 100 or US $150 of day-to-day medical expenses. Please find out how the International Travel Benefit works before you travel overseas and also read the scheme exclusions. Contact us to get detailed information or go to www.discovery.co.za

Cover for HIV medicines

If you need HIV medicines to prevent HIV infection from mother-to-child transmission, occupational and traumatic exposure to HIV or sexual assault, call us immediately on 0860 99 88 77, as treatment must start as soon as possible.

Benefit tips...
Call 0860 999 911 in an emergency L et us know about your admission as soon as possible M ake sure you know how the International Travel Benefit works before going overseas

Cover for going to casualty

If you are admitted to hospital from casualty, we will cover the costs of the casualty visit from your Hospital Benefit, as long as we confirm your hospital admission.

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Hospital benefits
We cover you in hospital for emergency and planned hospital admissions. There is no overall limit for hospital cover on your plan. Your approved hospital admission is subject to your available cover on your Plan. You can go to any private hospital for emergency and planned admissions.

Important information about your hospital cover

Your hospital cover is made up of: the cover for the account from the hospital, and the cover for all other accounts, like accounts from your admitting doctor, anaesthetist or any approved healthcare expenses. We call these related accounts.

Accounts from your doctor and other healthcare services Your doctor or treating healthcare professionals accounts are separate from the hospital account and are called related accounts. Related accounts include any account other than the hospital account. Examples of related accounts are the account from the admitting doctor, anaesthetist and any approved healthcare expenses, like radiology or pathology, which you incur during your hospital stay. Refer to the section on how we cover healthcare professionals for detailed information on how we cover related accounts. Please contact us before you receive treatment for which we have not confirmed your benefits or to extend your hospital stay.

Limits, clinical guidelines and policies apply to some healthcare services and procedures in hospital. How we pay the account from the hospital We cover you in a private hospital for emergency and planned hospital admissions that you have confirmed with us. We cover your hospital account (the ward and theatre fees) at the rate agreed with the hospital. You have cover for a general ward, not a private ward.

Going to hospital can be a stressful experience. Discoverys HospitalXpress makes your admission to hospital convenient and seamless. This service offers you express pre-admissions and online tools to authorise your admission and confirm your cover. HospitalXpress also connects you to select partners, bringing you a range of value-added services at the reduced prices youre accustomed to as a Discovery member.

Benefit tips...
You can access the MaPS Advisor on www.discovery.co.za to search for healthcare professionals who we have an agreement with

In-hospital benefits

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Before you go to hospital for any planned procedure, you must:

see your doctor who will decide if it is necessary for you to be admitted make sure you know how the account from your admitting doctor will be covered choose which hospital you want to be admitted to find out how we cover other healthcare professionals, for example your anaesthetist call us on 0860 99 88 77 to confirm your hospital admission at least 48 hours before you go in. We will give you information that is relevant to how we will pay your hospital stay

Cover for Prescribed Minimum Benefits

In most cases, Discovery Health plans offer benefits which are far richer than the Prescribed Minimum Benefits. To access Prescribed Minimum Benefits, there are rules that apply: your medical condition must qualify for cover and be part of the list of defined Prescribed Minimum Benefit conditions. the treatment needed must match the treatments in the defined benefits. you must use designated providers in the Discovery Health network. This does not apply in lifethreatening emergencies. However, even in these cases, where appropriate and according to the rules of the Scheme, you will be transferred to a healthcare provider in the Discovery network otherwise we will pay up to 80% of the Discovery Health Rate. You will be responsible for the difference between what we pay and the actual cost of your treatment.

Benefit tips...
You must call us at least 48 hours before any planned procedure Y ou will be covered in full if you use doctors who we have an agreement with, relevant to your plan type G o to Do We Cover on www.discovery.co.za to find out more about our clinical rules and policies S ome treatments you receive while in hospital may need separate approval or benefit confirmation

If you do not confirm your admission, we will only pay 70% of the costs that we would normally cover. Please refer to cover for medical emergencies for more information.

Cover is subject to our rules

We pay medically appropriate claims. Your cover is subject to our scheme rules, funding guidelines and clinical rules. There are some expenses that you may incur while you are in hospital that your Hospital Benefit does not cover, for example private ward costs. Please be aware that certain procedures, medicines or new technologies need separate approval while you are in hospital. Please discuss this with your doctor or hospital. You can find out more about our clinical rules and policies for cover by contacting us or at www.discovery.co.za under Do We Cover.

More information on our approach to Prescribed Minimum Benefits is available on www.discovery.co.za

In-hospital benefits

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Your cover for healthcare professionals

Full cover for specialists who we have an agreement with You can benefit by using healthcare professionals who we have an agreement with as we will cover their approved procedures in full. These healthcare professionals, appropriate to your plan, are also the designated providers for Prescribed Minimum Benefits. You can access the MaPS Advisor on www.discovery.co.za to search for healthcare professionals who we have an agreement with. You may have a co-payment if you use other specialists If you are treated by a specialist who we do not have an agreement with, we cover you up to 100% of the Discovery Health Rate. You may have a co-payment if your specialist charges above these rates.

Other healthcare professionals We cover GPs and other healthcare services up to 100% of the Discovery Health Rate. We cover radiology and pathology up to 100% of the Discovery Health Rate.

Your cover for dental treatment

You need to pay a portion of your hospital or day-clinic account upfront for dental admissions. This amount varies, depending on your age and the place of treatment:
Members Members younger than 13 years Members 13 years and older Hospital R1 300 R3 300 Day clinic R650 R2 200

Your cover for investigations

Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy) We pay the first R2 600 of your hospital account from your Medical Savings Account. We pay the balance of the hospital account and your related accounts from your Hospital Benefit according to your plans benefits. A related account is the account from your admitting doctor, anaesthetist or any approved expense you incur during your hospital admission, other than the hospital account. Contact us for a detailed explanation of how we cover scopes or go to www.discovery.co.za MRI and CT scans If your MRI or CT Scan is done as part of an approved admission, we pay up to 100% of the Discovery Health Rate from your Hospital Benefit. If you are admitted for conservative back or neck treatment, or if the scan is unrelated to your admission, we pay the first R2 300 of the scan from your Medical Savings Account. We pay the balance of the scan from your Hospital Benefit, up to 100% of the Discovery Health Rate. Specific rules and limits apply to conservative back and neck scans. Contact us for a detailed explanation of how we cover MRI and CT scans or go to www.discovery.co.za

We pay the balance of the hospital account from your Hospital Benefit, up to 100% of the Discovery Health Rate. We pay the related accounts, which include the dental surgeons account, from your Hospital Benefit, up to 100% of the Discovery Health Rate. No overall dental limit There is no overall limit for dental treatment. We pay for all dental appliances, their placement and orthodontic treatment (including the related accounts for orthognathic surgery) at 100% of the Discovery Health Rate from your Medical Savings Account, as long as you have money available. Severe dental and oral surgery The Severe Dental and Oral Surgery Benefit covers a defined list of procedures, with upfront payments and no overall limits. This benefit is subject to authorisation and the Schemes rules and guidelines.

You can benefit by using healthcare professionals who we have an agreement with as we will cover their approved procedures in full

In-hospital benefits

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Unlimited healthcare services

Most of your in-hospital healthcare services have no overall limit. These are: GPs Specialists Allied healthcare professionals, like physiotherapists Pathology and radiology

Only the following healthcare services have an annual limit:

Hospital limits Cochlear implants, auditory brain implants and processors Internal nerve stimulators Hip, knee and shoulder joint prostheses Prosthetic devices used in spinal surgery Mental health benefit Alcohol and drug rehabilitation Terminal care benefit Chronic dialysis Annual limit R140 000 for each person for each benefit R106 000 for each person There is no overall limit if you get your prosthesis from a preferred supplier. If you choose not to, a limit of R33 000 will apply to each prosthesis. R21 000 for the first level, R42 000 for two or more levels, limited to one procedure for each person 21 days for each person 21 days for each person R28 000 for each person in their lifetime We cover these expenses in full if we have approved your treatment plan and you use a provider in our network. If you go elsewhere, you have to make a co-payment

* If you join the medical scheme after January, you wont get the full limit because it is calculated by counting the remaining months in the year.

Treatment in hospital that we cover from your day-to-day benefits

We cover the following treatment you get in hospital from your Medical Savings Account: Casualty treatment if you are not admitted Medicine to take home External medical items

In-hospital benefits

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Cover for chronic conditions

You have extensive cover for chronic conditions, HIV and AIDS and cancer.

We need to approve your application

We need to approve your application before we cover your condition from the Chronic Illness Benefit. To apply, contact us to get an application form or go to www.discovery.co.za. Complete the relevant application form with your doctor and send it to us. We will send you a letter detailing the cover available to you. We pay medicine up to a maximum of the Discovery Health Medicine Rate. The Discovery Health Medicine Rate is the price of medicine as well as a fee for dispensing it. Discovery Health has negotiated contracts with over 1 200 pharmacies, who have agreed to charge no more than this rate. If you use a pharmacy outside of this network, you will have to pay part of the dispensing fee charged by the pharmacy. Use our online MaPS Advisor on www.discovery.co.za to find a network pharmacy. Please note that the medicine list and the Chronic Drug Amount are updated from time to time based on regulatory changes and continued clinic appropriateness. Visit www.discovery.co.za or contact us for a detailed explanation of the cover offered through the Chronic Illness Benefit.

If you do not use healthcare professionals who we have an agreement with, you will have to pay part of the treatment costs yourself. Contact us for the latest copy of the treatment guidelines or go to www.discovery.co.za

Your cover for cancer treatment

Our Oncology Programme covers the first R200 000 of approved cancer treatment over a 12-month cycle. We do not limit your cancer treatment costs, but you will need to pay 20% of the costs of treatment that costs more than R200 000. We cover chemotherapy and oncology-related medicines up to the Discovery Health Medicine Rate. We pay consultations, radiotherapy, radiology, pathology, scopes and scans up to 100% of the Discovery Health Rate. You may be responsible to make a co-payment if your healthcare professional charges more than the Discovery Health Rate. Cancer treatment that qualifies as a Prescribed Minimum Benefits is always covered in full. Please call us to register on the Oncology Programme. Visit www.discovery.co.za for a detailed explanation of the cover offered through the Oncology Programme.

Chronic Illness Benefit

You have cover for a list of chronic conditions. You have full cover for approved medicine on Discovery Healths medicine list or up to a set monthly amount (Chronic Drug Amount) for medicine not on our list. You will be responsible for the balance if your medicine costs more than the Chronic Drug Amount. When you use MedXpress, Discovery Healths convenient medicine delivery service, you pay no delivery or administration fees. Discovery Healths qualified service agents can also advise you on the most cost-effective alternatives and you will always be charged at the Discovery Health Medicine Rate or less minimising co-payments. Call us on 0860 99 88 77 to make use of this free service.

What we cover as a Prescribed Minimum Benefit

The Chronic Illness Benefit covers certain diagnostic tests, consultations and medicines each year for the chronic conditions listed in the Prescribed Minimum Benefits, called the Chronic Disease List. This cover includes tests and consultations during the year for both the diagnosis and ongoing management for each condition.

Benefit tips...
Y ou must register on the DiscoveryCare programmes to access these benefits M ore details are available on www.discovery.co.za or you can contact us

Benefit tips...
Y ou must register for cover from the Chronic Illness Benefit. We offer you comprehensive cover for a list of conditions.

Cover for chronic conditions and oncology

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Cover for day-to-day medical expenses

We first pay your claims from your Medical Savings Account

We pay day-to-day medical expenses like GP visits, radiology and pathology from your Medical Savings Account, as long as you have money available. Your Medical Savings Account is an amount that you get at the beginning of the year or when you join Discovery Health. You have access to the full amount from day one. If you have funds in your Medical Savings Account at the end of the year, we will carry over these funds to the next year. If you run out of money in your Medical Savings Account before your claims add up to the Annual Threshold, you will have to pay for your day-to-day medical expenses yourself. If you leave Discovery Health or downgrade your health plan before the year is up, you will owe Discovery Health the portion of the Medical Savings Account you have used but have not yet paid back. Annual Medical Savings Account amounts*:
Main member Adult dependant Child ** R2 352 R1 764 R936

The Insured Network Benefit ensures you have no gaps in cover for GPs
We extend your day-to-day cover through the Insured Network Benefit by paying GP consultation fees when you have spent your annual Medical Savings Account deposit. We cover your consultations if you go to a GP in our network. The maximum number of consultations that we cover for a single member and a family each year depends on your plan type:
Family 4 consultations

Your Medical Savings Account is an amount that you get at the beginning of the year or when you join Discovery Health. You have access to the full amount from day one.

Single Member 2 consultations

This benefit only covers the consultation fee, we pay for any other healthcare services from your available day-to-day benefits. To find a GP in our network, use our MaPS Advisor on www.discovery.co.za or contact us.

* If you join the medical scheme after January, you wont get the full limit because it is calculated by counting the remaining months in the year. ** We count a maximum of three children when we calculate the annual Medical Savings Account amounts

Out-of-hospital cover

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How we make your Medical Savings account last longer

We pay these day-to-day expenses without using your Medical Savings Account: The Screening and Prevention Benefit covers certain tests at a Discovery Wellness Network provider, like blood glucose, blood pressure, cholesterol and body mass index. We also cover a mammogram, Pap smear, PSA (a prostate screening test) and HIV screening tests. Members 65 years or older and members registered for certain chronic conditions are also covered for a seasonal flu vaccine. We cover out-of-hospital claims for recovery after certain traumatic events from the Trauma Recovery Extender Benefit. The cover applies to the rest of the year in which the trauma took place, and to the year after your trauma. We pay for scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy) from your Hospital Benefit if its done in your doctors rooms. We pay up to 100% of the Discovery Health Rate. Please call us before you have a scope done in your doctors rooms to confirm your benefits.

Your cover for day-to-day healthcare services is limited to money in your Medical Savings Account
We pay for these healthcare services from your Medical Savings Account: GPs Specialists Allied healthcare professionals, like physiotherapists Radiology and pathology Dentistry Private nursing Prescribed and over-the-counter medicine External medical items Hearing aids Optical care MRI and CT scans: we pay the first R2 300 of your MRI or CT scan from your Medical Savings Account. We cover the balance of the scan from your Hospital Benefit up to the Discovery Health Rate. For conservative back and neck treatment, specific rules and limits may apply.

Benefit tips...
How to make the money in your Medical Savings Account go further: C hoose a GP in the Discovery Health GP Network C hoose a specialist who we have an agreement with U se generic medicines and dont pay for over-the-counter medicines (OTCs) from your MSA

The Discovery Health Medicine Rate

For medicine, we pay up to the Discovery Health Medicine Rate. The Discovery Health Medicine Rate is the price of medicine as well as a fee for dispensing it. Discovery Health has negotiated contracts with over 1 200 pharmacies, who have agreed to charge no more than this rate. If you use a pharmacy outside of this network, you will have to pay part of the dispensing fee charged by the pharmacy. Use our online MaPS Advisor on www.discovery.co.za or contact us to find a network pharmacy.

Out-of-hospital cover

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General exclusions
Discovery Health has certain exclusions. We will not pay for healthcare services related to the following, except where stipulated as part of a defined benefit or under the Prescribed Minimum Benefits.
General exclusion list 1. Cosmetic procedures and treatments 2. Otoplasty for bat ears, Portwine stains and blepharoplasty (eyelid surgery) 3. Breast reductions or enlargements and gynaecomastia 4. Obesity 5. Frail care 6. Infertility 7. Wilfully self-inflicted illness or injury 8. Alcohol, drug or solvent abuse 9. Wilful and material violation of the law 10. Wilful participation in war, terrorist activity, riot, civil commotion, rebellion or uprising 11. Injuries sustained or healthcare services arising during travel to or in a country at war 12. Experimental, unproven or unregistered treatments or practices 13. Search and rescue 14. Any costs for which a third party is legally responsible We also do not cover the complications or the direct or indirect expenses that arise from any of the exclusions listed above, except where stipulated as part of a defined benefit or under the Prescribed Minimum Benefits. If we apply waiting periods because you have never belonged to a medical scheme or have had a break in membership of more than 90 days before joining Discovery Health, you will not have access to the Prescribed Minimum Benefits during your waiting periods. This includes cover for emergency admissions. The benefits outlined in this guide are a summary of the plans registered in the medical scheme rules. These benefits are reviewed annually and amended in line with the requirements of the Medical Schemes Act and also take into account the requirements of the Consumer Protection Act where it relates to the business of a medical scheme.

Important tips when claiming

When claiming from Discovery Health for your medical costs, whether these are hospital, chronic or day-to-day, these steps apply.
Check with your healthcare professional if they have sent your claims to us to avoid duplicates Send your claims within four months, otherwise we will consider them expired and not pay them When sending claims, please make sure the following details are clear: 1. Your membership number 2. The service date 3. Your healthcare professionals details and practice number 4. The amounts charged 5. The relevant consultation, procedure or NAPPI code and diagnostic (ICD-10) codes 6. The name and birth date of the dependant for whom the service was done 7. If paid, attach your receipt or make sure the claim says paid Remember to always keep copies of your claims for your records To see the status of your claim, you can go to www.discovery.co.za

Claiming for healthcare after a motor vehicle accident

Discovery Health pays for your healthcare expenses when youre involved in a motor vehicle accident. According to the rules of the Discovery Health Medical Scheme, you need to lodge a claim with the Road Accident Fund. If your claim with the Road Accident Fund is successful and both Discovery Health Medical Scheme and the Road Accident Fund pay your medical expenses, youll need to reimburse the medical expenses paid by the Road Accident Fund to Discovery Health.

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You can send us your claims in the following ways

Email You can scan and email your claims to claims@discovery.co.za Post You can post your claims to the following address: Discovery Claims PO Box 784262 Sandton 2146 Claims drop-off boxes You can drop your claims in our claims drop-off boxes situated around the country in convenient places such as pharmacies and medical practices, as well as at most Virgin Active or Planet Fitness gyms.

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