C. D. 2020 policy document_Final.pdf · 0861 472 580 Underwritten by Page 3 of 23 Hippo Advisory Services(Pty) Ltd is an authorised Financial Services Provider | FSP 36088 |Steyn

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Hippo Advisory Services (Pty) Ltd is an authorised Financial Services Provider | FSP 36088 |Steyn City Capital Park | Block A, Erling Road, Dainfern | 2191 | www.hippoadvice.co.za

TABLE OF CONTENTS

A. Your Insurer ........................................................................................................................................ 3

B. Your Underwriting Manager ................................................................................................................ 3

C. Your Network Provider ........................................................................................................................ 3

D. General Terms and Conditions ............................................................................................................. 3

E. Claims ................................................................................................................................................. 4

F. Premiums ............................................................................................................................................ 4

G. Termination of Cover ........................................................................................................................... 4

H. Helpful Definitions ............................................................................................................................... 4

I. Detail of Healthcare Services ............................................................................................................... 8

J. Waiting period ...................................................................................................................................15

K. Exclusions ...........................................................................................................................................15

L. IMPORTANT - PLEASE READ CAREFULLY .............................................................................................17

This Policy replaces all previous Flexicare and Flexicare Plus Policies and all existing Policyholders will fall

under these Policy rules.

Statutory Notice

“This is not a medical scheme and the cover is not the same as that of a medical scheme.

This policy is not a substitute for medical scheme membership.”

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A. Your Insurer

Auto & General Flexicare and Flexicare Plus Option is underwritten by Auto & General Insurance

Company Limited (registration number 1973/016880/06) an authorised Financial Services Provider

(FSP 16354), which provides your insurance cover. The cover provided is subject to all the terms and

conditions explained in your policy document.

B. Your Underwriting Manager

Your Underwriting Manager, Kaelo Risk (Pty) Ltd, registration number 2008/019335/07 an

authorised Financial Services Provider (FSP 36931), is responsible for all administrative matters

relating to your Auto & General Flexicare and Flexicare Plus Option Policy which includes:

• Issuing of your Policy

• Processing of your claims

• Collection of your premium

You can reach Kaelo Risk on 0861 472 580 or email [email protected]

C. Your Network Provider

Kaelo Prime Cure (Pty) Ltd, registration number 1997/017429/07 (Prime Cure) is the provider of the

network which can be accessed as outlined in the rules below.

Prime Cure is an accredited Managed Care organisation who is contracted to provide all the managed

care services, processes, account payments and manage contracts of the provider network.

D. General Terms and Conditions

1. These general terms and conditions apply to every section of your policy. There are also terms

and conditions that apply to specific sections under your policy. You must ensure that you

understand all sections of your Policy and if you have any questions, please contact Kaelo Risk.

2. You accept that the sharing of your insurance information between insurers, including credit

information, for underwriting and claims purposes. It enables insurers to underwrite policies,

assess risks fairly and reduce fraudulent claims.

3. Your personal information will be processed and stored in line with the Protection of Personal

Information Act 4 of 2013.

4. You consent to your information being provided to another insurance company or its agents and

acknowledge that any information about you may be verified against legally recognised sources

or databases.

5. This policy is based on, and includes, any information or communication, verbal or written, made

by you or on your behalf.

6. Examples are given where necessary to explain certain concepts within the policy document.

These examples are for clarification purposes only and do not form part of the policy.

7. Any reference to the singular includes a reference to the plural and vice versa.


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8. Compensation Limits and all Premiums are inclusive of VAT at the standard rate of 15%. With the

direction of the Commissioner in terms of S20(7) of the VAT Act, this policy document together

with proof of payment of the insurance Premium constitutes a valid tax invoice. All amounts are

in South African Rand, including Premiums and any amounts we may pay to you.

9. Where an age is mentioned in the policy, it will be the age as on the last birthday.

E. Claims

1. Contracted Service Providers will submit accounts to Prime Cure or Kaelo Health for payment of

services rendered to Policyholders.

2. Should a provider send you a claim, you can post the claim to: Private Bag 3108, Houghton, 2041

or preferably email [email protected]

F. Premiums

1. Your insurance Policy will remain in force for as long as your Premium is received.

2. All Premiums due must be paid by the first working day of that month.

3. If any Premiums are outstanding for more than 15 days from the due date, your cover will be

suspended.

4. If any Premiums are outstanding for more than 31 days, your cover will be cancelled.

5. Your cover starts on the first (1st) calendar day of a particular month and cannot be backdated.

G. Termination of Cover

1. You may cancel this cover at any time, by giving 31 days, prior written notice to the Underwriting

Manager.

2. Cover or services provided will only be valid if the treatment or service was provided prior to the

termination date.

3. Premiums are payable up to and including the termination date.

4. In the event that any fraudulent act is committed by any Policyholder or any service provider,

the Underwriter or its Underwriting Manager reserves the right to immediately cancel this cover

and/or to institute legal proceedings against the relevant party to recover any losses.

Helpful Definitions

1. “100% of Cost”: the Agreed Rate between the Underwriting Manager or Network Provider and

the Contracted Service Provider.

2. “Accidental Event” or “Trauma”: any injury or treatment resulting from Accidental Harm.

Treatment for an Accidental Event will be provided up to a maximum of 90 days calculated from

the date of the Accidental Event, provided the treatment and services have been authorised and

are directly related to the Accidental Event.



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3. “Accidental Harm”: any injury caused by violent, unintentional, external and physical means.

4. “Acute Medicine”: medicine used for diseases or conditions that have a rapid start, severe

symptoms, and that need a short term of medicine treatment.

5. “Agreed Rate”: the specific rate, agreed upon between the Network Provider and Contracted

Service Providers, used to determine the Rand amount at which Contracted Service Providers

are refunded.

6. “Benefit”: the Rand amount payable by the Insurer or its Underwriting Manager to a Contracted

Service Provider for services rendered to a Policyholder.

7. “Benefit Plan”: the Kaelo Health option chosen for cover in terms of this Policy.

8. “Benefit Year”: the period from 01 January to 31 December of any year.

9. “Benefit Date”: the first day of the month on which benefits commence, following Waiting

Periods.

10. “Chronic Condition”: a disease that lasts 3 months or more and generally cannot be prevented

by vaccines or cured by medication, nor do they just disappear. A chronic disease can be treated

by medication that will be required to be taken for a lifetime.

11. The list of chronic diseases covered are listed in Clause H4.

12. “Chronic Medication” is medicine prescribed by a Medical Practitioner for an uninterrupted

period longer than 3 months. This medicine is used for a medical condition which forms part of

an approved list of chronic conditions as listed in Clause H4.

13. “Condition Specific Waiting Period”: a time period, from the starting date, during which

specified benefits and services are excluded from cover as outlined in the Policyholder Schedule.

14. “Co-Payment”: an amount, either specified in Rand or as a percentage, that is payable by a

Policyholder to a Contracted Service Provider and is not covered under this Policy.

15. “Contracted Service Provider”: any medical service provider contracted and designated by the

Network Provider as a Kaelo Health provider.

16. “Dependent”: means either the Eligible Spouse or Eligible child.

17. “Dependent No”: means the number assigned to each Insured covered under this Policy.

18. “Dependent Type”: means either the Principle Policyholder, Eligible Spouse or Eligible child

19. “Eligible Child”: a child born to either the Eligible Policyholder or Eligible Spouse, as defined, of

this Policy. An Eligible Child includes a legally adopted child, or stepchild of an Eligible

Policyholder. In the event that the Eligible Child reaches the age of 26 years, the child will no

longer be an Eligible Child and will therefore no longer be covered under this Policy. On the

attainment by the Eligible Child of 26 years, the Eligible Child may take up a new Policy in their

own capacity, within thirty (31) days of them reaching the aforementioned age, without any

additional Waiting Periods or Exclusions being applied. The above age limitation will not be

applicable to a Special Needs Child, as defined in this Policy.


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20. “Eligible Spouse”: the partner of the Eligible Policyholder with whom a spousal union exists,

whether by virtue of South African law or religious tenet. Where a person shares an abode with

an Eligible Policyholder in a spousal union and has done so for at least six months and lives

together in a manner accepted in common law as that of a married couple, the person shall be

regarded as an Eligible Spouse in terms of this Policy. Should an Eligible Policyholder have more

than one spouse who could qualify as an Eligible Spouse then that Eligible Policyholder must

make an irrevocable nomination of one (1) spouse as the Eligible Spouse.

21. “Netcare”: means Netcare911 EMS (Pty) Ltd, a wholly owned subsidiary of Netcare. Registration

Number 1996/006591/07

22. “Exclusions”: the list of services, conditions and events in Section J of this Policy, which are

excluded from cover under this Policy.

23. “Family”: means collectively the Policyholder, Eligible Spouse, Eligible Children and/or Special

Needs Child as defined in this document.

24. “Formulary”: means a list of codes, procedures and medicine covered by this Policy. This applies

to both acute and chronic medication, radiology, pathology, dentistry, optometry and

procedures in the Doctor’s rooms.

25. “General Practitioner” or “GP” or “Doctor”: is a Doctor, who provides primary Healthcare

Services and is also a Contracted Service Provider.

26. “Allocated provider”: all beneficiaries will be allocated 2 GP’s. The GP’s will be allocated as

beneficiaries visit a GP. The first visited GP will be allocated GP 1 (one) and the second GP visited

will be allocated as GP 2 (two)

27. “General Waiting Period”: a time period, commencing on the Starting Date, during which all

benefits and services, except those resulting from Accidental Harm, are excluded from cover.

28. “Hazardous Sport”: includes, but is not limited to, participation in or use of any of the following:

a. All forms of motorised/jet racing or motorised/jet aerobatics, whether by land, sea or

air;

b. Mountaineering, trekking or hiking above an altitude of 4 000 (four thousand) metres;

c. Hunting, shooting or deploying firearms in any manner other than for self-defense

purposes;

These above definitions apply regardless whether activities are performed privately, socially,

during practice sessions, while participating in organised events, as an amateur or a professional.

29. “Healthcare Services”: means all services detailed in Section I of this document.

30. “Hospital”: any institution in the territory of the Republic of South Africa, which provides

diagnostic and therapeutic facilities for surgical and medical diagnosis, treatment and care of sick

or injured persons by or under the supervision of Medical Practitioners or Specialists on a full-

time 24 hour basis.

31. “Illness”: any bodily disease or sickness which manifests in a Policyholder.


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32. “Insured” or “Insured Party”: means either the Policyholder, Eligible Spouse, Eligible Children

and/or Special Needs Child as defined in the this document.

33. “Insurer”: means Auto & General Insurance Company Limited (registration number

1973/016880/06) an authorised Financial Services Provider (FSP 16354) and licensed insurer.

34. “Insured Event”: any one accident and/or emergency and/or Illness that requires an Insured to

undergo certain medical treatment or advice.

35. “Policyholder”: the policyholder defined as the Principal policyholder in the associated

policyholder Schedule

36. “Medical Practitioner”: a qualified medical practitioner, who is registered to practice with the

Health Professions Council of South Africa.

37. “Medical Emergency”: Emergency medical condition means the sudden, and at the time

unexpected onset of a life – threatening health condition that requires immediate medical

treatment, where failure to provide medical treatment will result in serious impairment to bodily

functions, or serious dysfunction of a bodily organ or part, and would place the person’s life in

serious jeopardy.

38. “Over The Counter Medicine (OTC)”: OTC medication is medication advised and dispensed by a

pharmacist at a Prime Cure contracted network pharmacy for the treatment of minor Illnesses.

OTC medication is limited to the Prime Cure medicine formulary for OTC medicine.

39. “Principle Policyholder” or “Policyholder”: means the Insured defined in the Policyholder

Schedule, who applied for cover under this Policy and who has been accepted by the Insurer or

its Underwriting Manger as eligible for participation in the insurance cover provided by this

Policy.

40. “Policyholder Schedule”: means a document issued to the Policyholder by the Insurer or its

Underwriting Manager containing the personal details of each Insured, starting date of cover,

Policy Dependent Type, Premium, Policy Exclusions and Waiting Periods as defined in this policy.

41. “Policyholder Card”: the card issued by the Underwriting Manager to a Policyholder and which

indicates the Flexicare benefit plan and personal details of the Insured Parties. This can be digital,

or paper based.

42. “Policy”: collectively this document and any relevant Policyholder Schedule or annexes, all of

which shall apply in a unified way.

43. “Premiums”: the monthly amount due to the Insurer payable by, or on behalf of, the

Policyholder.

44. “Pathology”: the study of the cause and effects of diseases, especially the branch of medicine

that deals with the laboratory examination of samples of body tissues for diagnostic purposes.

45. “Permanent Disability”: any Accidental Harm or physical Illness that renders a person

permanently unable to work in their own or other occupation for which they are suited by

training, education or experience.

46. “Per Annum”: period from 01 January to 31 December of any year.


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47. “Provider Network”: a list of accredited multi-disciplinary providers contracted by the Network

Provider to deliver Healthcare Services to the Policyholder and Insured Parties.

48. “Qualifying Norms”: Spectacles are granted if the following norms are met:

a. An unaided visual acuity of worse than 6/9 on the Snellen scale for distance vision and

near vision.

b. A refraction requirement exceeding 0, 5 dioptre sphere and or 0, 5 dioptre cylinder on

distance vision and 1, 25 dioptre sphere on near vision.

c. For the granting of bi-focals, insured parties have to comply with both the distance vision

and near vision qualifying norms for both eyes.

49. “Renewal Date”: 1st January of each year or other date determined by the Insurer or its

Underwriting Manager upon which the benefits will be amended.

50. “Specialist”: a Medical Practitioner who has been registered in terms of regulations relating to

the Specialties and Sub Specialties in Medicine and Dentistry, published under Government

Notice Number R.590 of 29 June 2001, as amended/replaced from time to time.

51. “Special Needs Child”: means any child, including a legally adopted child or stepchild, of the

Policyholder, by virtue of either a physical or mental disability, is unable to financially support

themselves and remains reliant on the Policyholder for support and care.

52. “Starting Date”: the first day of the month on which cover commences under this Policy.

53. “Termination Date”: the effective date of expiry of cover under this Policy.

54. “Treatment”: any form of medical advice, diagnosis, care or treatment provided by a Medical

Practitioner for the purpose of treating or monitoring the medical condition of an Insured.

55. “Treatment Program”: a set of techniques designed to monitor the use of, and evaluate the

clinical necessity, appropriateness, and efficiency of health care services, protocols or

formularies, forming part of primary health care.

56. “TTO” or “To-Take-Out”: medication dispensed to an Insured by a Hospital’s pharmacy upon

discharge from Hospital.

57. “Underwriting Manager”: Kaelo Risk (Pty) Ltd (Registration No: 2008/019335/07), also trading

as part of the Kaelo Group of Companies.

H. Detail of Healthcare Services

1. Doctor (GP) Visits

• Doctor (GP) visits during office hours (Monday to Friday: 08h00 - 17h00, Saturdays: 08h00 -

12h00) are 100% covered at the Agreed Rate.

• All out-of-hospital consultations of medical nature are covered, including minor procedures

performed in the rooms as listed in the Network Provider approved codes.


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• This benefit is unlimited if you visit a Contracted Doctor (GP), authorisation required from

the 7th GP visit per beneficiary. Members must allocate 2 GP’s from the list of contracted

providers. Members may change their allocated GP’s at any time.

• How to find your Doctor or GP?

▪ You may call, the call centre 0861 472 580 or visit the Network Provider website on

www.primecure.co.za.

2. Acute Medicine (short term medicine)

You can receive unlimited acute medicine if:

• The acute medicine is prescribed by your allocated Doctor (GP) The medication is on the

Network Provider acute medicine formulary.

• The acute medicine can be provided by a dispensing allocated and contracted GP, or by a

Contracted Network Provider Pharmacy.

• Authorisation from the 7th visit doctor visit per beneficiary must have been obtained

• Acute medication on the formulary is available without a co-payment.

• The Acute Medicine will not be covered if it is prescribed by a GP that is not contracted to

the Network Provider or if obtained from a non-contracted pharmacy or authorization was

not obtained from the 7th visit per beneficiary.

3. Over The Counter (OCT) Medicine

OTC medicine may only be obtained at a Network Provider contracted pharmacy and on advice

by the pharmacist.

The OTC benefit is limited to R130 per script to a maximum of R390 per Insured per annum (a

maximum of 3 events per beneficiary per annum).

The following Insured Parties may obtain one flu vaccination per Benefit Year:

• Children between 6 (six) months and 6 (six) years of age.

• Pregnant women.

• Policyholders 65 (sixty-five) years of age and older.

• Adults and children who are registered for Chronic Medication.

4. Chronic Medication (long term medication)

If Chronic Medication has been prescribed and registered with Prime Cure and prescribed

by your allocated Network Provider and is on Formulary your medication will be covered

in full.


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You must register for the benefit, in order to do so you can obtain the chronic application

form from the Network Provider website (www.primecure.co.za) or from your contracted

Doctor (GP).

Your Doctor (GP) needs to email the completed chronic application form to

[email protected].

Chronic Medication is available only for the following conditions:

• Addison’s disease;

• Asthma;

• Bipolar mood disorder;

• Bronchiectasis;

• Cardiac failure;

• Cardiomyopathy;

• Chronic renal disease;

• COPD (chronic obstructive pulmonary disease);

• Coronary artery disease;

• Crohn’s disease;

• Diabetes insipidus;

• Diabetes mellitus type 1;

• Diabetes mellitus type 2;

• Dysrhythmias;

• Epilepsy;

• Glaucoma;

• Haemophilia;

• HIV (see details below);

• Hyperlipidemia (high cholesterol);

• Hypertension;

• Hypothyroidism;

• Multiple sclerosis;

• Parkinson’s disease;

• Rheumatoid arthritis;

• Schizophrenia;

• Systemic lupus erythematosus;

• Ulcerative colitis.



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After approval of the Chronic Medication, you can obtain your Chronic Medication at a

contracted pharmacy or from Medipost (the courier pharmacy who will deliver your

Chronic Medication to the address you selected at no additional cost).

5. HIV Medication

Unlimited HIV medication is covered from date of registration of your Chronic

Medication by your Doctor (GP).

6. HIV Programme

The HIV programme is designed to optimise the health and wellbeing of HIV positive

patients.

You must register for the benefit, in order to do so you can obtain the Network Provider

HIV registration form from the Network Provider website (www.primecure.co.za) or

from your allocated contracted Doctor (GP).

Your Doctor (GP) needs to email the completed chronic application form to

[email protected]

The HIV management programme includes:

• Voluntary counselling and testing.

• Antiretroviral therapy, prophylactic antibiotics and supplements.

• Treatment support and guidance.

• Pathology and monitoring (including CD4, viral load, liver enzymes, cholesterol,

glucose, urine tests) according to protocols.

• Treatment of related infections, according to the Network Provider procedures and

specifications.

• Emergency post exposure medication is provided if the accidental exposure is

brought to the attention of the Network Provider within 72 (seventy-two) hours.

• Prevention of mother-to-child transmission (PMTCT).

7. Dentistry

The benefit is only covered if a Prime Cure contracted dentist is visited.

This benefit includes:

• A single consultation for a full mouth examination per Insured per Benefit Year.

• Preventative treatments - one per Insured per Benefit Year. Includes cleaning,

scaling, polishing and fluoride treatment (for children under the age of 12 (twelve)

years only).

• Pre-authorisation is required for 4 (four) or more restorations (repairs to teeth), or

5 (five) or more composite fillings per Family per Benefit Year.

• Diagnosis and treatment for pain and sepsis.



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• Infection control.

• Oral hygiene advice on how to keep the mouth and teeth clean to prevent dental

problems.

• Extractions - pre-authorisation required for 5 (five) or more extractions.

• Local anesthetic.

• Oral radiography - pre-authorisation is needed for three (3) or more X-rays

(maximum 4 (four) per Family per Benefit Year.

• Emergency root canal only for pain and sepsis

After hours treatments are limited to one visit per Family in the Benefit Year for pain

and sepsis, although you may visit any dentist, you may have to pay cash and claim back

from the Network Provider. The Network Provider will refund the Policyholder

according to the Agreed Rate.

8. Optometry

Eye examination are limited to one per Insured per Benefit Year and includes a visual

evaluation, screening and a diagnosis.

Spectacles and lenses will be limited to one pair in a 24 month-period, and include

standard, high quality clear plastic lenses (CR39 lenses), single vision and bi-focal lenses.

Qualifying Norms will apply. Qualifying norms apply.

Frames will be limited to a single frame in a 24 month-period.

The choice of frame is specified to be from a quality selection of the Network Provider

approved range of frames - any frames not on the range will result in the Policyholder

paying the difference in costs.

The optometry benefit is subject to availability at Contracted Service Providers only.

9. Radiology

Black and white X-rays and soft tissue ultrasounds according to a list of the Network

Provider approved codes, are paid at the Agreed Rate.

An allocated Network Provider contracted Doctor (GP) must request the Radiology tests

and you have to take the Radiology request form to the radiologist. Authorisation from

the 7th GP visit per beneficiary must have been obtained.

10. Maternity

Flexicare covers 2 (two) sonar scans per pregnancy per insured per Benefit Year.

This can be provided by your allocated Doctor (GP), or a Network Provider contacted

radiologist as referred by the Doctor (GP). Only 2D scans are covered. Prenatal care is

not covered.


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11. Pathology

Pathology tests are limited to the Network Provider list of approved Pathology codes

and is paid at the Agreed Rate.

The tests must be requested by your allocated contracted Provider Doctor (GP) and the

test must be done by a Network Provider contracted pathology laboratory – Ampath,

Lancet, Pathcare or Lab24.

Authorisation from the 7th GP visit per beneficiary must have been obtained

12. MyDoctor

Our call centre is managed by qualified nurses who give clinical advice and information

which includes:

• Symptom checkers

• First aid information

• Medication library

• Medical procedure information

• Know your numbers – health vault to store your health readings

• Health tutorials – Policyholders can subscribe to weekly health information around

specific topics such as quitting smoking, excessive drinking, asthma, diabetes,

allergies, back pain etc.

13. Road Accident Cover

Kaelo Risk will assist policyholders with legitimate claims against the Road Accident

Fund.

Any benefits payable by the road accident fund equal to the cost incurred by Kaelo Risk

needs to be ceded by the Insured to the Insurer or its Underwriting Manager.

14. Death Cover

In the event of the death of an Insured, the benefits listed below shall be paid to either:

• The surviving Eligible Spouse or Principal Policyholder.

• Eligible Children (or their legal guardians in the event of them being minors).

• Failing any of the above, the benefit shall be paid to the Insured estate.

• Accidental Harm pays R15 750


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15. Ambulance

Medical emergencies will be transported to a State Facility and Trauma and Accident

emergencies will be transported to a Contracted Hospital casualty by Netcare 911 –

Limited to R17 850 per event. Netcare 911 to be contacted for an authorisation that will

be provided to the casualty.

All Insured Parties are required to access these services via the Netcare 911 toll-free line

on 082 911 (24/7/365) or by direct referral from the call centre on 0861 472 580 (Monday

to Friday, 08:00 – 17:00 only).

16. Accident Cover

a. Casualty treatment (Accidental Events only)

▪ Emergency out-patient services will be provided in the case of Accidental Harm

to an Insured when the Insured needs out- patient treatment and is transported

to the relevant Hospital by Netcare 911

▪ The benefit payable is equal to the actual cost of the services that are provided,

but only to the limit of R17 850 (seventeen thousand eight hundred and fifty

rand) per event

▪ Netcare911 will authorise the benefit amounts to the relevant Hospital in the

case of an accident (caused by an Accidental Event) Services must be rendered

at a Network Provider Hospital casualty.

▪ No benefit is payable under this clause for services that are related to an Illness.

▪ Any Specialist or follow up visits for medical cases will not be covered under the

Kaelo Health Casualty Treatment benefit.

b. In-Hospital treatment (Accidental Events only)

Applicable to Flexicare Plus Option only

▪ Emergency in-patient services will be provided for in case of Accidental Harm to

an Insured for in-patient Hospital treatment.

▪ Authorisation must be obtained by contacting the call centre on 0861 472 580.

▪ The benefit payable is equal to the actual cost of the services that are provided,

subject to a maximum of R350 000 (three hundred and fifty thousand rand) per

event.

▪ The benefit covers treatment and services for a 90-day period calculated from

the date of the Accidental Event. All treatment during this period must be pre-

authorised by contacting the call centre on 0861 472 580.

▪ Services must be rendered at a contracted Network Provider Hospital.

▪ No benefit is payable under this clause for services that are related to an Illness.

▪ Any Specialist or follow up visits will not be covered if not related to the

Accidental Event.


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c. Stabilisation (Accidents Only)

▪ Unlimited stabilisation of the Insured at the scene of the accident by Netcare

911 before being transported to the appropriate Hospital.

I. Waiting period

Any applicable General Waiting Period and/or Condition Specific Waiting period as

prescribed in this policy will be outlined in the Policyholder Schedule.

• Waiting Periods shall be applied to the cover of the relevant Insured, from the time that such

Insured cover starts under this Policy.

• The Insurer or its Underwriting Manager reserves the right to change the application of Waiting

Periods, by giving notice of 31 days before such a change.

J. Exclusions

Claims or benefits will not be paid for or in the event of any of the following:

• Cosmetic surgery.

• Suicide, attempted suicide or willful injury to oneself.

• The use of any drug or narcotic, legal or illegal, unless prescribed by and taken in according to the

instructions of a Medical Practitioner.

• The failure of a policyholders to follow any medical advice given by a Medical Practitioner.

• Any incident, Illness, accidental harm or event directly or indirectly caused by the excessive

consumption of alcohol or alcoholism.

• Any incident, Illness, accidental harm or event directly or indirectly caused by the Insured having

a blood alcohol content more than thirty milligrams per one hundred milliliters of blood.

• Nuclear weapons, nuclear material, ionising radiations or contamination by radioactivity from any

nuclear fuel, or from any nuclear waste, or from the combustion of nuclear fuel which includes

any self-sustaining process of nuclear fission.

• Participation, or attempted participation, by any Insured in any of the following:

a. Any defence force, police force, medical rescue service, firefighting service, correctional

b. services facility or the disarming of explosives;

c. Aviation activities where any medical expense is insured by another party (excludes fare-

paying passengers in a licensed passenger carrying aircraft);

d. Any Hazardous Sport;

e. Any form of race or speed test (other than on foot or involving any non-mechanically

propelled vehicle, vessel, craft or aircraft).


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• Riots, wars, political acts, public disorder, or any acts, or attempted acts, of any of the following:

a. Civil commotion, labour disturbances, riot, strike, lock-out or public disorder or any act to

bring about any of the above;

b. War, invasion, act of foreign enemy, hostilities, civil war;

c. Mutiny, military rising or usurped power, martial law or state of siege, insurrection,

rebellion or revolution;

d. Any act directed to overthrow or influence any state or government or any provincial,

e. Local or tribal authority with force or by means of fear, terrorism or violence;

f. Any act to further any political aim, objective or cause, or

g. To bring about any social or economic change, or in protest against any state or

government, or any provincial, local or tribal authority, or for the purpose of inspiring fear

in the public;

• Terrorism.

• The act of any lawfully established authority in controlling, preventing, suppressing or in any

other way dealing with any event referred to in point 9 above.

• Any claim, service or benefit that does not form part of this Policy.

• Any claim that is not part of the list of approved tests or medication formularies.

• The following procedures, items, services, service providers or events:

a. External prosthesis;

b. Any appliances, like wheelchairs, beds or convalescing equipment, etc.

c. All specialised dental procedures like crowns, bridges, dental implant related

procedures, orthognathic surgery, temporo-mandibular joint (“TMJ”)

d. surgery, labial frenectomy, bone augmentations, bone or tissue regeneration

e. Rehabilitation, frail care or hospice services;

f. Step-down facilities;

g. TTO (to-take-out) medicines;

h. Any treatment related to infertility.

• All services obtained from a non- contracted provider, where no pre-authorisation was obtained

for treatment at a contracted provider. Any criminal act or attempted criminal act by an Insured,

which include the submission of any fraudulent information, or other fraudulent means, to get

any benefit or service under this Policy;

• Expenses incurred for non-emergency transport charges whether or not such vehicle, vessel or

craft is specifically designed for the purposes of medical emergency transport.

• Any act by an Insured that willfully exposed the Insured to danger, except where such act was in

order to save human life or prevent accidental harm.


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• In the case of Trauma or Accidental Harm, benefits exclude any treatment that is unrelated to

the Trauma or Accidental Harm.

K. IMPORTANT - PLEASE READ CAREFULLY

Disclosure and Other Legal Requirements

(This notice does not form part of the Insurance Contract or any other document)

As a short-term insurance policyholder, or prospective policyholder, you have the right to the following

information:

• The Financial Advisory and Intermediary Services and Short-term Insurance Acts require

compliance, by the Insurer (who is the product supplier), Underwriting Manager and your

intermediary/broker, with the Acts, FAIS General Code of Conduct and Policyholder Protection

Rules to make informed decisions about the insurance products that you purchase. It also aims to

ensure that your Product Supplier, Underwriting Manager and intermediary/broker render

financial services honestly, fairly, with due skill and diligence and in your interests and the integrity

of the financial services industry.

• You will receive two Disclosure Notices (one from your broker/intermediary and one from your

Underwriting Manager and Insurer) at the inception of your policy and at each subsequent

Renewal (or Anniversary) date. The Disclosure Notices contain information about your Insurer,

Underwriting Manager and intermediary/broker, together with information about the Ombud and

Financial Sector Conduct Authority. Should you experience any difficulties in obtaining required

details, please contact your intermediary/broker for further assistance.

ABOUT YOUR INTERMEDIARY/BROKER

Your intermediary/broker should provide you with their Disclosure Notice within a reasonable time

from the time you are provided with a quotation, take out a policy or amend your policy. If they do

not do so, even after you have requested it, please contact the Insurer or Underwriting Manager to

assist.

ABOUT THE UNDERWRITING MANAGER (UMA)

• The UMA is Kaelo Risk (Pty) Ltd, an authorised Financial Service Provider - Registration no.

2008/019335/07 (FSP no 36931) e-mail: [email protected] website: www.kaelo.co.za

• Kaelo Risk (Pty) Ltd is approved for Category 1 Short Term Insurance Personal Lines

Physical address: 2nd Floor, The Oval, East Wing,

Wanderers Office Park, 52 Corlett Drive, Illovo,

2196

Postal address P.O. Box 3083, Houghton, 2041

Telephone number – 0861 493 587 / 011 759

9600

Facsimile number - +27 86 501 8521


http://www.kaeloxelus.co.za/

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Details of Compliance Officer Eas-e-Comply (Pty) Ltd

Tel: 0861 266 759

Email: [email protected]

Compliance Practice number: C028

Physical Address: 80 The Valley Road, Parktown

2196

Details of Claims Department Email: [email protected]

Subject: Claims

Tel: 0861 493 587

Details of the Complaints Department

All complaints must be reduced to writing and

any of our representatives will be able to provide

you with a copy of our complaints procedure on

request.


Subject: Complaints or Escalations

Tel: 0861 493 587

• In the past financial year the UMA has not received more than 30% of its income from the Insurer.

• The UMA has a written mandate (Binder agreement) to act on behalf of the insurer.

• The UMA holds Professional Indemnity Insurance Cover.

• The UMA is paid regulated binder fee

• The UMA may from time to time have representatives that are rendering services under

supervision.

ABOUT YOUR INSURER

Name Auto & General Limited Company Registration Number 1973/016880/06

FSP Number 16354

VAT No 4890105085

Postal Address Auto & General Park

1 Telesure Lane,

Riverglen,

Dainfern,

2191

Physical Address Auto & General Park

1 Telesure Lane,

Riverglen,

Dainfern, 2191

Tel Number (011) 489 4000

Fax Number (011) 715 7301 Website http://www.autogen.co.za/





http://www.autogen.co.za/

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Details of the compliance department Telesure Group Services (Pty) Ltd is Hippo

Advisory Services’ nominated compliance

practice.

Compliance can be contacted on:

Tel : 0860 99 99 54

Email : [email protected]

Details of complaints department

All complaints must be reduced to writing and

any of our representatives will be able to provide

you with a copy of our complaints procedure on

request.

Tel: 0860 10 90 59


• The premium and all accompanying charges are detailed on your policy schedule. Your

intermediary/broker receives up to, but never exceeding, the regulated maximum commission

payable in terms of the Short-Term Insurance Act.

• This policy is a Health & Accident policy offered under the Short-Term Insurance Act.

• If premium is paid by debit order:

o it may only be in favour of one person and may not be transferred without your

approval; and

o the insurer must inform you at least 31 days before the cancellation thereof, in

writing, of its intention to cancel such debit order.

• Consequence of Non-Payment: Should you fail to make payment on or before the due date /

payment date, you have a period of grace for the payment of premiums. You will be notified of the

non-payment and given a grace period of 15 days to pay the outstanding premium. Your policy will

remain in force for a period of 15 days after that due date / payment date. In the case of a monthly

policy, this provision will apply with effect from the second month of the currency of the policy.

• It remains the sole responsibility of the policyholder to ensure that full premiums are paid on the

due date.

Other matters of importance:

• You will be informed in the event of any material changes to this information provided.

• You will be given reasons, in writing, by the Insurer in the event of a claim being repudiated, as

well as full details of steps that can be taken, and timelines that you will need to stick to, if you do

not agree with the Insurer’s decision.


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• The insurer must give you at least 31 days’ written notice of its intention to cancel the policy.

• You will always be entitled to a copy of the policy free of charge.

• If you decide that this cover does not suit your needs and no benefit has yet been claimed, you

have 31 days from when you receive our policy documents to cancel the policy in writing and any

premiums that have been collected before then, will be refunded within 31 days after your

cancellation notice is received.

How to institute a claim:

• You don’t need to worry about claiming because your contracted service provider will lodge your

claim on your behalf. However, in the rare circumstance that this does not happen, please contact

us on any of the Claim contact details given above.

• Once your claim has been approved, funds will be paid directly to the contracted provider.

How to submit a paid claim for refund

There will be times that you have to pay cash when you visit a healthcare provider (“a

provider”). A provider can include a specialist, non-contracted General Practitioner or

casualty Cash payments can happen when you choose a provider that is NOT contracted

to our network. In the event that you have made a cash payment to a provider, you will

need to claim this back in the form of a refund.

Please ensure you submit the following documentation to Kaelo Prime Cure.

• A copy of your ID

• A copy of the account you received from the provider that supports your refund claim.

• Your receipt from the provider that shows proof of payment

• Any refunds exceeding R3 000.00 must be accompanied by proof of banking details (Either a

cancelled cheque or bank stamped statement /letter)

• Your refund will be processed within 14 days of receipt of all the information

• Where no proof of bank details have been supplied to Prime Cure we will not be held responsible

for any payment made into an incorrect account.

You can submit your documents either via email using the following email address:

[email protected] or via post using the following postal address: Private Bag 2108,

Houghton, 2041

Please note that you have 120 days to submit your refund claim.

How to submit a complaint:

• If you have a complaint, please contact us on any of the Complaint contact details given above.

• Please note that all complaints must be addressed to us in writing.



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• If any complaint about your intermediary/broker is not resolved to your satisfaction, you may

submit your complaint to the FAIS Ombudsman, whose address appears at the foot of this

notice.

• If any complaint to the UMA is not resolved to your satisfaction, please contact the Insurer and

if it is still not resolved to your satisfaction, you may submit your complaint to the Short Term

Insurance Ombudsman or the FSCA, whose addresses appear at the foot of this notice.

Warning:

• Do not sign any blank or partially completed application forms.

• Complete all forms in ink.

• Make notes of what was said to you and keep all documents handed to you.

• Do not be pressurised into buying the product.

• Study the policy with care immediately when it is received. If you have any uncertainties, discuss

these with your intermediary/broker or UMA.

• Incorrect or non-disclosure by you of relevant facts may influence the assessment of a claim.

Other Contact Details:

THE FAIS OMBUDSMAN

Physical Address: Kasteel Park Office Park,

Orange Building, 2nd Floor, c/o Nossob &

Jochemus Street, Erasmus Kloof, Pretoria, 0048

Postal Address: P O Box 74571, Lynnwood

Ridge, 0040

Telephone: +27 (0) 12 470 9080

Facsimile: +27 (0) 12 348 3447


Website: www.faisombud.co.za

SHORT-TERM INSURANCE OMBUDSMAN

Physical Address: 1 Sturdee Avenue, Cnr Bolton

& Baker Roads, First Floor, Block B, Rosebank.

Postal Address: P.O. Box 32334, Braamfontein,

2017.

Telephone: 011 726 8900 / 0860 726 890

Fax: 011 726 5501


Website: www.osti.co.za

FINANCIAL SECTOR CONDUCT AUTHORITY

Physical Address: Riverwalk Office Park, Block B,

41 Matroosberg Road (Cnr Garsfontein Road &

Matroosberg Road), Ashlea Gardens, Extension

6, Menlo Park, Pretoria.



http://www.faisombud.co.za/


http://www.osti.co.za/

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Postal Address: P.O. Box 35655, Menlo Park,

Pretoria.

Telephone: +27 (0) 12 428 8000

Facsimile: +27 (0) 12 347 0221

E-mail: [email protected]

Website: www.fsca.co.za

SHARING OF INSURANCE INFORMATION

• Insurers share information with each other regarding policies and claims with a view to prevent

fraudulent claims and obtain material information regarding the assessment of risks proposed

for insurance. By reducing the incidents of fraud and assessing risks fairly, future premium

increases may be limited. This is done in the public interest and in the interest of all current

and potential policyholders.

• The sharing of information includes but is not limited to information sharing via the Information

Data Sharing System operated by TransUnion ITC on behalf of the South African Insurance

Association. By the insurer accepting or renewing this insurance, you or any other person that

is represented herein, gives consent to the said information being disclosed to any other

insurance company or its agent.

• You also similarly give consent to the sharing of information in regard to past insurance policies

and claims that you have made. You also acknowledge that information provided by yourself

or your representative may be verified against any legally recognised sources or databases.

• By insuring or renewing your insurance you hereby not only consent to such information

sharing, but also waive any rights of confidentiality with regards to underwriting or claims

information that you have provided or that has been provided by another person on your

behalf.

• In the event of a claim, the information you have supplied with your application together with

the information you supply in relation to the claim, will be included on the system and made

available to other insurers participating in the Information Data Sharing System.

USE OF YOUR PERSONAL INFORMATION

• When you enter into this policy you will be giving us your personal information that may be

protected by data protections legislation, including but not only, the Protection of Personal

Information Act, 2013 (“POPI”). We will take all reasonable steps to protect your personal

information.


http://www.faisombud.co.za/

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• You authorise us to:

• Process your personal information to

• Communicate information to you that you ask us for.

• Provide you with insurance services.

• Verify the information you have given us against any source or database.

• Compile non-personal statistical information about you.

• Transmit your personal information to any affiliate, subsidiary or re-insurer so that we can

provide insurance services to you and to enable us to further our legitimate interests

including statistical analysis, re-insurance and credit control.

• Transmit your personal information to any third-party service provider that we may appoint

to perform functions relating to your policy on our behalf.

• You acknowledge that this consent clause will remain in force even if your policy is cancelled or

lapsed.

WAIVER OF RIGHTS

• No intermediary/broker, Underwriting Manager or Insurer may request or induce in any

manner a client to waive any right or benefit conferred on the client by or in terms of any

provisions of the General Code of Conduct, or recognise, accept or act on any such waiver by a

client. Any such waiver is null and void.

CONFLICT OF INTEREST

• We have considered the conflict of interest provisions in terms of the FAIS Act 37 of 2002 and

the Policyholder Protection Rules and have not identified any actual or potential conflicts of

interest, either ownership interest, financial interest, third party relationships, associates or

distribution channels as defined.

We adopted a values-based approach where the spirit of the legislation is embraced. This is

reviewed at least annually and reported on to the Financial Sector Conduct Authority. A conflict

of interest management policy is available to clients upon request


Documents

C. D. 2020 policy document_Final.pdf · 0861 472 580 Underwritten by Page 3 of 23 Hippo Advisory Services(Pty) Ltd is an authorised Financial Services Provider | FSP 36088 |Steyn