Above Threshold Benefit

 
 
 
 

Available on the Executive, Comprehensive and Priority plans

Once the claims you have sent to us add up to the Annual Threshold, we pay the rest of your claims form the Above Threshold Benefit (ATB), at the Discovery Health Rate or a portion of it. The Executive and Comprehensive plans have an unlimited ATB, and the Priority plans have a limited ATB. However, before we pay claims from the Above Threshold Benefit, you may have to pay some of your day-to-day medical expenses from your pocket. We call this a Self-payment Gap (SPG).

Please note: We do not pay certain claims, for example over-the-counter medicine, from the Above Threshold Benefit.

How it works

We add up the Discovery Health Rate of the day-to-day claims that you send us. When your day-to-day claims reach a fixed rand amount – known as the Annual Threshold - we pay claims from the Above Threshold Benefit.

We set the Annual Threshold amount at the beginning of each year. The number and type of dependants (adult or spouse or child) on your plan will also determine the amount. The overall Above Threshold Benefit limit on the Priority Plans is a combined limit, and does not apply to each member separately.

Limits and exclusions

  • Certain claims, such as those for Schedule 0, 1 or 2 medicine, are not paid for once in the ATB.
  • When you enter your ATB, your medical expenses are covered at the applicable Discovery Health Rates according to your plan type, subject to certain annual limits.
  • Remember, the annual limits apply to claims from the ATB and MSA. You can read more about this in your health plan guide.
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