The Above Threshold Benefit
The Above Threshold Benefit (ATB) only applies to the Executive, Comprehensive and Priority Plans. Once your day-to-day expenses reach a fixed rand amount (called the Annual Threshold), Discovery Health Medical Scheme will pay your claims from the Above Threshold Benefit.
We pay claims up to the Discovery Health Rate, depending on the limits for any specific treatment and conditions. This benefit has an overall limit on the Priority Plans. 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.
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 Plan 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.