The Comprehensive Series

Whether you need to be hospitalised for a planned hospital procedure or need emergency cover, the Comprehensive Series offers cover in a private hospital with no overall limit

We cover you in any private hospital for emergency and planned hospital admissions that you have authorised with us.

Emergency cover when you need it most

In an emergency, go straight to hospital but call us or get someone to call us within 12 hours.

If you need medically-equipped transport in a medical emergency, call 0860 999 911. This line is managed by highly qualified emergency personnel who will send the most appropriate air or road emergency evacuation transport.

Cover for planned hospital admissions

Please call us at least 48 hours before you go to hospital to confirm your admission.

You must use a network hospital on the Delta option

On the Classic and Essential Delta Comprehensive options, you are covered in full at hospitals in the Delta Hospital Network. For planned admissions at any other private hospital, you must pay a deductible of R4 150.

The Delta Hospital Network

Gauteng

• Arwyp Medical Centre
• Life Bedford Gardens Hospital
• Netcare Bougainville Private Hospital
• Life Brenthurst Clinic
• Life Carstenhof Clinic
• Clinix Private Hospital – Lesedi
• Clinix Private Hospital – Sebokeng
• Clinton Clinic
• Emfuleni Medi-Clinic
• Life Fourways Hospital
• Legae Private Hospital
• Lenmed Clinic Limited
• Life Little Company of Mary
• Louis Pasteur Hospital
• Midvaal Private Hospital
• Morningside Medi-Clinic
• Life Robinson Private Hospital
• Life Roseacres Clinic
• Suikerbosrand Clinic
• The Donald Gordon Medical Centre
• Life Wilgeheuwel Hospital

Day Hospitals

• Birchmed Day Clinic
• Boksburg Medical & Dental Centre
• Brooklyn Surgical Centre
• Centurion Eye Hospital
• Clinton Clinic
• Constantia Park Medical & Dental Centre
• Cormed Clinic
• Fauchard Clinic
• Fordsburg Clinic
• Johannesburg Clinic
• Johannesburg Eye Hospital
• Karibu Day Clinic
• Kilnerpark Narko Clinic
• Mayo Clinic
• Medgate Day Clinic
• Medkin Clinic
• Mercidoc Day Clinic
• Ocumed
• Oprimed
• PJ Schutte Theatre Unit
• Silverton Medical & Dental Centre
• The Healthy Eye
• Visiomed Eye Laser Clinic
• Wilgeheuwel Day Clinic

Eastern Cape

• Life New Mercantile Hospital

Free State

• Life Rosepark Hospital
• Universitas Private Hospital

Day Hospitals

• Bethlehem Medical Centre
• CityMed Theatre
• Bloemfontein Eye Clinic

KwaZulu Natal

• Life Chatsmed Garden Hospital
• Life Entabeni Hospital
• Ethekwini Hospital
• Midlands Medical Centre
• Life Westville Hospital

Day Hospital

• Bluff Medical & Dental Centre

Western Cape

• Cape Town Medi-Clinic
• Life Claremont Hospital
• Life Kingsbury Hospital
• Mitchells Plain Medical Centre
• Panorama Medi-Clinic
• Vergelegen Medi-Clinic

Day Hospitals

• Khangella Eye Theatre
• Panorama Laser Clinic
• Parow Medical & Dental Centre
• Wesfleur Private Clinic

No overall limit

There is no overall hospital limit on the Comprehensive Series. Limits, clinical guidelines and policies apply to some healthcare services and procedures.

We have negotiated with the majority of specialists to guarantee that when you use a specialist in our payment arrangements we pay them directly at our agreed rate. This means that when consulting a specialist in our payment arrangements you will be covered in full.

Full cover for specialists participating in our payment arrangements

You can benefit by using healthcare professionals participating in our payment arrangements because we will cover their approved procedures in full. If you are a Classic Comprehensive Plan member, you benefit from access to the broadest range of specialists whom we pay in full, which represents over 87% of specialist interactions.

You may have a co-payment if you use other specialists

If you are treated in hospital by a specialist who does not participate in one of our payment arrangements, we cover you up to 200% of the Discovery Health Rate on Classic Comprehensive and up to 100% of the Discovery Health Rate on Essential Comprehensive.

Other healthcare professionals

We cover GPs and other healthcare services up to 200% of the Discovery Health Rate on Classic Comprehensive and up to 100% of the Discovery Health Rate on Essential Comprehensive.

We cover radiology and pathology up to 100% of the Discovery Health Rate on all plans.

Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy)

We pay the first R1 900 of your hospital account from your day-to-day benefits. We pay the balance of the hospital account and your related accounts from your Hospital Benefit. A related account is the account for your admitting doctor, anaesthetist and any approved expense you incur during your hospital admission, other than the hospital account.

MRI and CT scans

If you are in hospital as part of an approved hospital admission, we cover your MRI or CT scan up to the Discovery Health Rate from your Hospital Benefit.

If you are admitted for conservative back or neck treatment, we pay the first R2 100 of the scan code from your day-to-day benefits. We pay the balance from your Hospital Benefit up to the Discovery Health Rate. You are limited to one MRI or CT scan a year for conservative back and neck treatment.

You need to pay a portion (deductible) of your hospital or day clinic account upfront for dental admissions. This amount varies depending on the member’s age and the place of treatment.

We pay the balance of the hospital account from the Hospital Benefit up to 100% of the Discovery Health Rate.

We pay the related accounts, which include the dental surgeon and anaesthetist’s accounts, from the Hospital Benefit up to 100% of the Discovery Health Rate.

No overall dental limit

There is no overall limit for dental treatment. However, all dental appliances and orthodontic treatments (including the related accounts for orthognathic surgery) are paid at 100% of the Discovery Health Rate from your day-to-day benefits, up to an annual sub-limit of R16 000 a person. We pro-rate this benefit according to when you join the medical scheme.

Severe dental and oral surgery

The Severe Dental and Oral Surgery Benefit covers a defined list of procedures, with no deductible and no overall limits. This benefit is subject to authorisation and the Scheme’s clinical entry criteria.

Most of your in-hospital healthcare services have no overall limit. These include:

• GPs
• Specialists
• Allied healthcare professionals, for example physiotherapists
• Pathology and radiology
• HIV cover if you are registered on the HIVCare Programme

Your cover for chronic conditions

The Chronic Illness Benefit offers you flexible cover for chronic conditions – you always have the option of full cover through our medicine list or the choice of using any medicine up to a set monthly amount.

You have extensive and flexible cover for a comprehensive list of chronic conditions. You have full cover for approved medicine on Discovery Health’s medicine list (formulary) or up to a set monthly amount for medicine not on our list.

The medicine list (formulary) for Comprehensive Plans has more medicines on it than most other plans. If you choose to use medicines that are not on the medicine list, you have a higher set monthly amount available to you than on most other plans.

We pay medicine up to a maximum of the Discovery Health Medication Rate. We need to approve your chronic condition before it is covered from the Chronic Illness Benefit.

The Delta Range

You have cover with no co-payment for approved chronic medicine if you use a Delta network pharmacy. If you do not use a Delta network pharmacy, a 25% co-payment applies.

Your cover for medical technology and expensive medicine

The Specialised Medicine and Technology Benefit covers the latest treatments, medicines and technologies.

You have additional cover for a defined list of the latest treatments through the Specialised Medicine and Technology Benefit, up to R200 000 for each person. Please call us to see whether your treatment qualifies.

You have access to the Overseas Treatment Benefit, where you are covered when you travel to seek evidence-based

healthcare not available in South Africa at a registered healthcare professional, up to a limit of R500 000 for each person each year. You will need to pay and claim back from us when you return to South Africa.

Entry criteria and a co-payment of up to 20% applies to both benefits.

Your cover for cancer treatment

DiscoveryCare’s Oncology Programme covers you for cancer treatment.

DiscoveryCare’s Oncology Programme covers the first R400 000 of your approved cancer treatment over a 12-month cycle, in full. Cover is unlimited once your cancer treatment costs go over this amount but you need to pay 20% of the costs of all further treatment from your pocket.

Radiology and pathology approved for your cancer treatment is also covered. Cancer treatment that falls within the Prescribed Minimum Benefits is always covered in full, with no co-payment. Please call us to register on the Oncology Programme.

We cover chemotherapy and any oncology-related medicines up to the Discovery Health Medication Rate. Consultations, radiotherapy, radiology, pathology and scans are paid up to the Discovery Health Rate. You may be responsible for a co-payment if your healthcare provider charges more than the applicable Discovery Health Rate.

The Medical Savings Account puts you in control of your day-to-day medical expenses. Any unused money is carried over to the following year.

We pay for your day-to-day medical expenses like GP visits, radiology and pathology from your Medical Savings Account, at the cost incurred, as long as you have money available. You may need to pay for your day-to-day medical expenses if you have run out of money in your Medical Savings Account before your claims add up to the Annual Threshold. Once your claims add up to the Annual Threshold, we pay the rest of your claims from the Above Threshold Benefit.

Extending your day-to-day cover

Early detection and prevention of diseases is vital to your wellbeing. The Screening and Prevention Benefit pays for a range of healthcare services that help to prevent and screen for diseases that would otherwise go unnoticed.

Discovery Health pays claims for some day-to-day expenses to make the money in your Medical Savings Account
last longer:

• The Screening and Prevention Benefit covers a range of healthcare services, including the following tests at a Discovery Wellness Network provider: blood glucose, blood pressure, cholesterol and body mass index. The benefit also covers a mammogram, Pap smear, PSA and HIV screening tests. Members from the age of 65 and members registered for certain chronic conditions are also covered for a seasonal flu vaccine from this benefit.
• We will cover out-of-hospital claims for your recovery after certain traumatic events from the Trauma Recovery Extender Benefit. The cover applies for the rest of the year in which the trauma takes place, as well as the year after your trauma.
• We will pay for endoscopies done in your doctor’s rooms (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy) without using your day-to-day benefits as we pay these accounts from the Hospital Benefit. We pay up to 200% of the Discovery Health Rate if you are on a Classic Comprehensive Plan and up to 100% of the Discovery Health Rate if you are on an Essential Comprehensive Plan. Please call us before you have a scope in your doctor’s rooms to confirm your benefits.

The Insured Network Benefit ensures you have no gaps in cover for GPs and pathology in our network

The Insured Network Benefit covers GP consultation fees, and blood tests requested using the Discovery Health pathology form, at our network providers, to ensure that you don’t have any gaps in cover.

We further extend your day-to-day cover through the Insured Network Benefit. When you have spent your annual Medical Savings Account deposit:

• We cover the full cost of your consultation fees if you go to a GP in our network. We pay the claim directly to the GP.
• We cover blood tests at our network providers if your GP or specialist requests the appropriate tests using the Discovery Health pathology form.

The Above Threshold Benefit offers extra day-to-day cover

Your day-to-day cover is further extended through the Above Threshold Benefit – a safety net that covers you when your expenses addup to a set amount.

The Comprehensive Series includes an Above Threshold Benefit that gives you further day-to-day cover when your Medical Savings Account runs out and when your day-to-day claims add up to a set rand amount. On the Comprehensive Series, the Above Threshold Benefit is unlimited.

For you to get to your Above Threshold Benefit, we add your claims up to your Annual Threshold. Here are the amounts that we add up:

• For Premier Rate specialists, we add up the Premier Rate. For non-participating specialists, we add up the Discovery Health Rate.
• For generic medicine, we add up 100% of the Discovery Health Medication Rate. For non-generic medicines, we add up 75% of the Discovery Health Medication Rate. Over-the-counter medicines do not add up to your Annual Threshold.
• We add up the Discovery Health Rate for all other healthcare services.

We add up the amount to the benefit limit available.

No annual limit on some day-to-day healthcare services

We pay for these healthcare services from your Medical Savings Account with no annual limit:

• GPs
• Specialists
• Allied healthcare professionals, for example physiotherapists
• Pathology and radiology
• Endoscopies (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy)
• MRI and CT scans

Limits on some day-to-day healthcare services

Some of your day-to-day benefits have limits. These limits apply to claims paid from your Medical Savings Account and Above Threshold Benefit.

* We pro-rate this benefit according to when you join the medical scheme.

Medical Savings Account Amounts

* Medical Savings Account amounts as a percentage of total contributions

** We count a maximum of three children when we work out the monthly contribution.

 Annual Threshold amounts

Discovery Health does not cover certain healthcare services. You can find a full list of these exclusions here.

We market our Discovery Health Plans through independent and accredited financial advisers. If you want a financial adviser to help you choose a Health Plan to suit the needs of your family, please send us your contact details and we will contact you.