BCIMA

 

Benefits

Benefits and Exclusions 2018

benefits
benefits

NEW HIV/AIDS BENEFIT From 1 January 2015 BCIMA will provide an HIV/AIDS benefits to its members. This benefit is subject to registration on the BCIMA HIV/AIDS Disease Management Program If you register on the HIV/AIDS Program, you will have access to the following benefits: • Medicine to treat HIV/AIDS (antiretroviral therapy) • Medicine to treat and prevent opportunistic infections related to HIV/AIDS, including multi-vitamins where appropriate (a doctor's prescription and pre-authorisation is required for all medicines, including multi-vitamins) • All pathology tests related to monitoring the disease

Exclusions

The following exclusions will apply to a member and/or his dependants.

  1. Treatment arising out of an injury for which any other party is liable, unless the Board is satisfied that there is no reasonable prospect of recovering medical costs from the other party. In cases where the parties concerned repudiate a claim, after deliberation, the member shall be entitled to such benefits for the services rendered, as would have applied under normal conditions, irrespective of the lapse of time.
  2. Treatment by any person not registered with a recognised professional body constituted in terms of an Act of Parliament.
  3. Willfully self-inflicted injuries.
  4. Travelling expenses.
  5. Operations, treatment and examinations for cosmetic purposes which has no connection with any illness, accident or other medical Disability. No benefits will be paid in respect of any examinations, operations or surgical procedures relating to jaw, ear, eyelids or abdomen without prior written approval of the Board, who will be entitled to request further information.
  6. Obesity.
  7. Injuries arising from professional sport or any speed contests or trials.
  8. Appointments cancelled or not kept by members.
  9. Medical examinations or mass inoculation of employees initiated by employers.
  10. The purchase of: patent medicines and propriety preparations; bandages and aids: patient foods, including baby foods; contraceptives and slimming preparations; tonics as advertised to the public; household, biochemical and herbal remedies; vitamin and mineral supplements.
  11. Private nursing fees in respect of both mother and child after childbirth.
  12. Treatment of infertility and impotence.
  13. When illness or injury is directly attributable to failure to carry out the instructions of a medical practitioner.
  14. Any illness arising out of and in the course of the member’s employment, which constitutes a valid claim in terms of the Workmen’s Compensation Act, or a Stated Benefit Policy or a Personal Accident Policy.
  15. Injury arising from an accident whilst travelling in an aircraft.
  16. Venereal disease and HIV/AIDS.
  17. Alcoholism, narcotism and drug addiction.
  18. Injuries arising from parachute jumping and hang-gliding.
  19. Injuries resulting from unrest situations.
  20. Operations for nasal or breast reconstruction.
  21. Hospitalisation, including theatre fees, ward and theatre drugs and other medical requirements, in respect of organ transplant of any nature unless provided for in the relevant Annexure.
  22. Treatment relating to cystic fibrosis of the lungs and pancreas, haemophilia and spina bifida.
  23. Uvulo-palatopharyingioplasty (UPPP).
  24. Costs arising from accommodation and nursing services rendered in a convalescent, old age home or similar institution catering for the aged or chronically ill.
  25. Alzheimer’s disease.

 

LIMITATION OF BENEFITS

  1. The amount payable in any one financial year, i.e. the period from 1 January to 31 December inclusive, shall be limited only to the extent of the maximum benefits.
  2. Services rendered during one financial year will be paid against the limit of that particular year.
  3. If membership is obtained during a particular financial year the maximum limit available will be calculated on a pro-rata basis from the date of admission to the end of the year.
  4. In case of prolonged illness, the Board can request consultation with any particular specialist nominated by the Board in consultation with the attending practitioner. If the specialist’s advice is not acted upon, no further benefits will be allowed for that particular illness.
  5. In cases where a specialist, except an eye specialist, is consulted without the recommendation of a general practitioner, the amount of assistance to be rendered by the Fund may, at the discretion of the Board, be limited to the amount that would have been paid to the general practitioner for the same service.
  6. Unless otherwise decided by the Board – hospitalisation in respect of psychiatric treatment shall be limited to a stay of not more than 21 days per family in any financial year.
  7. Benefits for the following medication will only be allowed if prescribed by a dermatologist: Dianne and Roaccutane.
  8. No claim shall be payable by the Fund, if, in the opinion of the Medical Advisor, the health care services in respect of which such claim is made, is not appropriate and necessary for the symptoms, diagnosis or treatment of the medical condition at an acceptable and reasonable level of care.
  9. Sonar in pregnancy. One payment; follow-up or further sonar may be paid on submission of a motivational letter from the doctor.

 

CONTRIBUTIONS

  1. Contributions are structured according to gross monthly or weekly salary or pensionable earnings.
  2. Contributions are due weekly in arrears and payable not later than the 2nd working day of the following week.

 

WAITING PERIODS AND SPECIAL EXCLUSIONS

In terms of the criteria laid down by the Medical Schemes Amendment Act, the Schemes may impose the following waiting periods:

  1. a general waiting period of three (3) months; and/or
  2. a twelve (12) month exclusion on a pre-existing medical condition/s, for that specific condition/s.
  3. a loading may be imposed upon a member according to the late joiner penalties as prescribed in the Medical Schemes Act.

 

ABBREVIATIONS

AT = Agreed Tariff according to:
the National Health Reference Price List (NHRPL), or
the Uniform Patient Fee Schedule (UPFS), or
the contracted fee or negotiated fee, or
the Universal negotiated fee, or
the BCIMA Tariff (BT), whichever is applicable or
DSP = Designated Service Provider
OTC = Over the counter pharmacy prescription
PAT = Pharmacy Advised Therapy
PMB = Prescribed Minimum Benefits.
SAOA = South African Optometric Association.

IMPORTANT NOTICE

This is a summary of benefits which are applicable in terms of the Rules of the Scheme. A copy of the Rules may be obtained from the administrator if so required.

The Rules of the Scheme will always take precedence over this summary.

Download product brochure 2018.