Discovery Classic Priority medical aid plan: 2018

View all plans in this scheme.
Please note that these benefits are still being updated as more information is made available to us. Always consult with your broker before making final decisions regarding your healthcare cover.

COSTS and OVERVIEW:
Classic Priority
Quick Overview
Main: Adult: Child:
Total Cost pm: R3,214 R2,534 R1,286
Savings: R9,636 R7,596 R3,852
Self Payment:
(per year, if you use up all your savings)
R4,604 R3,074 R808
Above Threshold: R12,080 R8,610 R4,170
Gap (optional): KaeloXelus: R350 per family
(R600 per family if anyone is 60yrs+)
Overal Limit: Unlimited
PMBs: Day-to-day expenses for PMBs (eg. cancer) are always paid for by the scheme, according to protocols. Find out more
Children: Pay for maximum 3 children
  • Scheme rate is 200%, and most day-to-day expenses are paid by scheme, or from savings, or from threshold benefit.
  • There is a self payment gap before threshold is reached. The threshold is limited.
  • There are co-payments for certain procedures
  • Discovery does pay for most maternity expenses and some preventative benefits such as mammograms and pap smears
  • You get unlimited cancer cover, with a co-payment after R200,000
  • Travel insurance and international treatment
  • Diagnosis and treatment of the 270 PMBs is always paid by scheme, in and out of hospital, according to protocols.
See full benefits below

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IN HOSPITAL PROCEDURES:
Classic Priority
Benefits Gap benefits
Payout Rate for Specialists:
  • 200% scheme rate
  • Network specialists covered in full
Fusion Gap:
  • Up to 700% scheme rate for specialists and other providers
  • In case of admission related to accident:
    -R300 per day, for days 1-13
    -R600 per day for days 14-20
    -R1,200 per day for days 21-30
  • R350pm per family. More Info or download application below.
Discovery Gap:
  • 400% of scheme rate for specialists only
  • Additional R2,500-R20,000 for specialist costs not fully covered by this
  • This additional benefit can also pay-in for some out-of-hospital expenses related to admission
  • No benefit for co-payments
  • Starts at R90 (single) and R150(family). More Info or contact Discovery below
Hospital Choice:
  • Unlimited
  • N/A
Specialised Radiology:
  • If not related to admission or for conservative back or neck treatment: R3,050 co-payment for the scan, and R2,750 towards the hospital account is paid by you.
  • Otherwise, paid by scheme at 100% scheme rate
Fusion Gap:
  • Gap covers co-payments for most scopes and a defined list of other procedures, incl MRIs etc See full list
Discovery Gap:
  • No benefit
Supplementary Services: (Physio, etc)
  • Covered in full for professionals with payment arrangement with Discovery
  • Otherwise, 200% scheme rate
Fusion Gap:
  • Up to 700% scheme rate for specialists and other providers
Discovery Gap:
  • 400% of scheme rate for specialists only
  • Additional R2,500-R20,000 for specialist costs not fully covered by this
Transplants:
  • Covered
Fusion Gap:
  • Up to 700% scheme rate for specialists and other providers
Discovery Gap:
  • 400% of scheme rate for specialists only
  • Additional R2,500-R20,000 for specialist costs not fully covered by this
Co-payments:
  • Scopes: R3,900 co-payment
  • Adenoidectomy, myringotomy (grommets), tonsillectomy, conservative back treatment: R2,800 co-payment
  • Arthroscopy, functional nasal procedures, hysterectomy, laparoscopy, hysteroscopy, endometrial ablation: R7,300 co-payment
  • Reflux surgery, spinal surgery, joint replacements: R15,000 co-payment
  • No co-payment if procedure can and is done out-of-hospital
  • In-hospital dentistry: co-payment required for some admissions. See dentistry benefit for details
Fusion Gap:
  • Gap covers co-payments for most scopes and a defined list of other procedures, incl MRIs etc See full list
Discovery Gap:
  • No benefit
Alternatives to hospitals:
  • Administration of IV, iron treatments, steroids and immunoglobulins when a hospital admission is not required: covered
  • Care for venous ulcers, diabetic foot ulcers, pressure sores and other moderate to severe wounds for patients who do not require hospital admission: covered
  • Terminal care: R57,000 per person, per lifetime
  • Cancer: Unlimited palliative care cover for approved care at home
  • No benefit
Casualty:
  • Accident and trauma (emergency) related costs covered
Fusion Gap:
  • Casualty costs not covered by medical aid, in case of emergency treatment: R12,800 per incident. Cover also applies to costs covered by savings account.

Discovery Gap:
  • No additional benefit
Other:
  • Cochlear implants: R214,500
  • Internal Nerve stimulators: R147,300
Fusion Gap:
  • Death or permanent disability: R12,000. If cause of death was accidental: R24,000.
  • If Principal member of medical aid passes away or becomes disabled: medical aid contributions will be paid for six months, up to R4,400 per month. Gap premium is also waived for 6 months
  • In event of vehicle accident where policy holder was not at fault: Gap will provide all legal assistance, fully covered.

Discovery Gap:
  • Discovery has a Suplementary Gap that pays out for disability, etc.

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OUT OF HOSPITAL BENEFITS:
Classic Priority
Benefits Gap benefits
GP consultations:
  • Paid from day-to-day benefit
  • If in Self Payment Gap, GP consults and kid casualty visits covered by scheme, if using network provider
  • Out of hospital treatment for conditions that are PMBs is always paid for by the scheme (not out of savings), but according to protocols
  • No benefit
Childcare:
  • If in Self Payment gap, unlimited GP visits and kid casualty visits covered by scheme if using network providers
  • No benefit
Specialists consultations:
  • Paid from day-to-day benefit at 100% scheme rate, unless Discovery has payment arrangement with specialist
Fusion Gap:
  • Benefits apply to procedures done in doctor's rooms or day clinics if the medical aid pays for precedure from risk (not from savings)
  • R350pm per family. More Info or download application below.
Discovery Gap:
  • An additional benefit (between R2,500 and R20,000) can pay-in for some out-of-hospital expenses related to admission
  • Starts at R90 (single) and R150(family). More Info or contact Discovery below
Pathology:
  • Paid from day-to-day benefit
See above
General radiology:
  • Paid from day-to-day benefit
See above
Specialised radiology:
  • Paid from day-to-day benefit
  • TBC
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefits. Includes allied, therapeutic and psychology services
Main M1 M2 M3+
R10,200 R14,450 R18,700 R22,100
Fusion Gap:
  • No benefit

Discovery Gap:
  • R2,500 - R20,000 which can be used for specified out-of hospital expenses related to an admission

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MATERNITY BENEFITS:
Classic Priority
Benefits Gap benefits
Hospital stay:
  • Covered at 200% scheme rate for specialists
Fusion Gap:
  • Up to 700% scheme rate for specialists and other providers
  • Premature birth, more than 6 weeks:R12,000 lump payment
  • In case of admission related to premature birth (mother or child):
    -R300 per day, for days 1-13
    -R600 per day for days 14-20
    -R1,200 per day for days 21-30
  • R350pm per family. More Info or download application below.
Discovery Gap:
  • 400% of scheme rate for specialists only
  • Additional R2,500-R20,000 for specialist costs not fully covered by this
  • Starts at R90 (single) and R150(family). More Info or contact Discovery below
Consultations:
  • 8 consults, paid by scheme
  • Nuchal translucency or Non-Invasive Prenatal Test, paid by scheme
  • Certain blood tests, paid by scheme
  • Five pre- or postnatal classes with registered nurse
  • For two years after birth: two visits for baby with GP, Paediatrician or ENT; one six week post-birth consult with midwife, GP or gynae; one nutritional assessment; two mental health consults; one lactation consult
  • No benefit
Scans:
  • 2 x ultrasound scans, now paid by scheme
  • No benefit

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CANCER (ONCOLOGY):
Classic Priority
Benefits Gap benefits
Overall coverage (in and out of hospital):
  • Unlimited. After the first R200,000, a 20% co-payment applies for non-PMB cancers
  • All cancer-related treatments are covered at 100% scheme rate
  • Specialised medicine and technology: No benefit, unless PMB
  • Unlimited palliative care cover for approved care at home
Fusion Gap:
  • Full cover for the 20% co-payments
  • R350pm per family. More Info or download application below.

Discovery Gap:
  • Provides up to R100,000 per year to cover shortfalls on approved cancer-related claims once you have reached oncology threshold
  • Starts at R90 (single) and R150(family). More Info or contact Discovery below

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DENTISTRY:
Classic Priority
Benefits Gap benefits
Dentistry: In-hospital:
  • For severe dental and oral surgery, a defined list of procedures is included, with no upfront payment and no overall limit
  • Otherwise, you need to pay a portion of your account upfront:
    • If you are younger than 13, you pay R2,200 for admission to hospital, and R1,000 for admission to a day-clinic
    • If you are 13 and older, you pay R5,650 for admission to hospital, and R3,650 for admission to day-clinic
    • Balance of account is paid by scheme at200% scheme rate for anaesthetists and 100% scheme rate for other accounts.
Out-of-hospital:
  • Standard dentistry: from day-to-day benefit
  • Specialised dentistry: from day-to-day benefit, limited to R16,300 per person. This limit includes claims for orthognathic surgery, dental appliances and their placements
Fusion Gap:
  • Up to 700% scheme rate for specialists and 600% for other in-hospital providers
  • Dental reconstruction due to due to trauma or oncology treatment: R40,000 per event
  • Full cover for in-hospital co-payments
  • R350pm per family. More Info or download application below.
Discovery Gap:
  • 400% scheme rate for specialists
  • Additional R2,500-R20,000 for specialist costs not fully covered by this
  • No benefit for co-payments)
  • Starts at R90 (single) and R150(family). More Info or contact Discovery below
Orthodontics:
  • See above
  • No benefit
Maxillo Facial Surgery:
  • See above
Fusion Gap:
  • Dental reconstruction due to due to trauma or oncology treatment: R40,000 per event
  • Full cover for in-hospital co-payments
Discovery Gap:
  • See above

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MEDICATION:
Classic Priority
Benefits Gap benefits
Chronic:
  • No benefit
Acute (presrcibed) medication:
  • Schedule 3 and above, from day-to-day benefit, up to the limits below
Main M1 M2 M3
R18,600 R22,600 R27,200 R29,700
  • No benefit
Over-the-counter:
  • Paid from day-to-day benefit
  • These do not add up to the annual threshold, and are not paid for from it
  • No benefit
Birth Control: TBC
  • No benefit
On Discharge:
  • See "Acute Medicine" benefit
  • No benefit
Biological:
  • No benefit
  • No benefit

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OPTOMETRY:
Classic Priority
Benefits Gap benefits
Optometry:
  • R4,550 per person, including surgery to correct refractive errors, paid from day-to-day benefit
  • 20% discount on frames and lenses at a network optometrist
  • No benefit

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MENTAL HEALTH:
Classic Priority
Benefits Gap benefits
In-hospital:
  • Major affective disorders, anorexia and bulimia: 21 days for admissions or 15 out-of-hospital consultations
  • Acute stress disorder accompanied by recent significant trauma: 21 days for admissions or 12 out-of-hospital consultations
  • Other mental health admissions: 21 days in-hospital
  • Alcohol and drug rehab: 21 days in-hospital
  • All admissions are covered in full at a network facility, or at 80% scheme rate at a non-network facility
  • No benefit
Out-of-hospital:
  • See above
  • Otherwise, paid from day-to-day benefit. Claims for psychologists and social workers fall into the supplementary benefit sub limit ie:
M M1 M2 M3+
R10,200 R14,450 R18,700 R22,100
  • No benefit
Trauma:
  • Offers out of hospital claims for recovery after traumatic events for rest of year, and year after that

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OTHER BENEFITS:
Classic Priority
Benefits Gap benefits
General Appliances:
  • External appliances limited to R39,400 per family from day-to-day benefit
  • Cochlear implants: R214,500
  • No benefit
1.1. Hearing Aids:
  • R19,000 per family paid from day-to-day benefit
  • No benefit
1.2. Wheelchairs:
  • See "General Appliances" limit
  • No benefit
Dialysis:
  • Covered in full if you use network provider
  • No benefit
HIV:
  • Covered if on the HIV Care program
  • No benefit
Emergency Transport:
  • No benefit
International Insurance:
  • Up to R5 million per person on each journey for emergency medical costs while outside South Africa
  • Emergency medical evacuations from certain sub-Saharan African countries back to South Africa
  • No benefit
Other:
  • Internal nerve stimulators: R147,300
  • DNA Analysis: paid in full from day-to-day benefit or 50% from above threshold
  • Second opinion from Cleveland Clinic for life-threatening and life-changing conditions. 50% co-payment
  • Death or permanent disability: R12,000. If cause of death was accidental: R24,000.
  • If Principal member of medical aid passes away or becomes disabled: Medical aid contributions will be paid for six months, up to R4,400 per month. Gap premium is also waived for 6 months
  • In event of vehicle accident where policyholder was not at fault: Gap will provide all legal assistance, fully covered.

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WELLNESS/PREVENTATIVE BENEFITS:
Classic Priority
Benefits Gap benefits
Flu vaccination:
  • Covered, for 65 yrs+
  • No benefit
Pneumonia vaccines:
  • To be confirmed
  • No benefit
Back Rehabilitation Programme: TBC
  • No benefit
Biometric Screening:
  • Covered
  • No benefit
Child Immunisation: TBC
  • No benefit
Pap Smear:
  • Covered, every 3 years
  • No benefit
Mammogram:
  • Covered, every 2 years
  • If you qualify, you can get Breast MRI and once-off BRCA test for breast screening
  • No benefit
PAS Test:
  • Covered
  • No benefit
HIV Test:
  • Covered
  • No benefit
Other:
  • Kids' assessment, including height, weight, head circumference and health and milestone tracking
  • No benefit

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PROSTHETICS:
Classic Priority
Benefits Gap benefits
Overal Limit: .
Sub-limits:
  • Shoulder joint prostheses: no limit, unless you use non-network supplier, in which case R40,000 limit applies
  • Major joints surgery: no limit, unless you use non-network supplier, in which case 80% scheme rate and R30,000 per prosthesis limit applies
  • Spinal surgery: no limit, unless you use non-network supplier, in which case R25,000 limit for first level nd R51,000 for two or more levels. Limted to one procedure per person per year.
  • An additional R40,000 per sublimit, per event

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    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised