Discovery Executive medical aid: 2017 vs 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:
Executive
2018 costs In brief:
What’s new in 2018?
Main: Adult: Child:
Cost 2018: R5,950 R5,950 R1,134
Cost 2017: (R5,544) (R5,544) (R1,055)
Gap (optional): KaeloXelus: R350 per family
(R600 per family if anyone is 60yrs+)
Overal Limit: Unlimited overall, with sub-limits
PMBs: Day-to-day expenses for PMBs (eg. cancer) are always paid for by the scheme, according to protocols. Find out more
Savings: R17,844 R17,844 R3,396
Self Payment: R2,506 R2,506 R454
Above Threshold: Unlimited overall, with sublimits for some benefits. Find out more
Children: Pay for maximum 3 children
    In 2018:
  • Get a second opinion from Cleveland clinic, paid by Discovery
  • More benefit for overseas treatment not available and available in SA
  • Specialised radiology no longer paid out of savings
  • There is now a self payment gap
  • In-hospital dentistry no longer paid out of savings
  • Out of hospital maternity paid by Discovery
  • Up to $1million for travel insurance
See below for more changes.
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Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family


IN HOSPITAL PROCEDURES:
Executive
2017 v 2018 benefits Gap benefits Notes
Payout Rate for Specialists:
  • 300% scheme rate
  • Network specialists covered in full
  • GPs and other professionals: 200% scheme rate
Fusion Gap:
  • Up to 800% scheme rate for specialists and 700% for 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:
  • 500% 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

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Hospital Choice:
  • Unlimited
  • N/A
Specialised Radiology:
  • Co-payment: none
  • Sublimit: none
  • Rate: 100% scheme rate
  • N/A
Supplementary Services: (Physio, etc)
  • 200% scheme rate
Fusion Gap:
  • Up to 800% scheme rate for specialists and 700% for other providers
Discovery Gap:
  • 500% 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 800% scheme rate for specialists and 700% for other providers
Discovery Gap:
  • 500% of scheme rate for specialists only
  • Additional R2,500-R20,000 for specialist costs not fully covered by this
Co-payments:
  • In-hospital dentistry: co-payment required for some admissions. See dentistry benefit for details
Fusion Gap:
  • TBC
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:
  • International Second Opinion: members can obtain second opinion from Cleveland Clinic
  • Overseas Treatment Benefit: R750,000 for treatment not available in South Africa, and R300,000 for voluntary in-hospital treatment outside SA (new benefit). Both options have 20% co-payment
  • Specialised medicine and technology: R200,000 per person with a 20% co-payment
  • Cochlear implants: R214,500
  • Internal Nerve stimulators: R147,300
Fusion Gap:
  • If part of oncology treatment, gap will cover the co-payment for the specialised medicine benefit
  • 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:
  • If part of oncology treatment, gap will cover the co-payment for the specialised medicine benefit, up to R100,000
  • Discovery has a Suplementary Gap that pays out for disability, etc.

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OUT OF HOSPITAL BENEFITS:
Executive
2017 v 2018 benefits Gap benefits Notes
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


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Childcare:
  • If in Self Payment gap, unlimited network GP visits and 2 kid casualty visits covered by scheme if using network providers
  • No benefit
Specialists consultations:
  • Paid from day-to-day benefit at 300% 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 by scheme
  • TBC
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit
  • Limited to:
    M M1 M2 M3+
    R21,200 R25,500 R29,800 R35,800
  • For a defined list of conditions you get unlimited cover for biokineticists, acousticians, physiotherapists, occupational therapists, and speech and language therapists. Speak to Discovery directly
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:
Executive
2017 v 2018 benefits Gap benefits Notes
Hospital stay:
  • 300% scheme rate
  • Up to R1,880 for private ward
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:
  • 500% 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

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Consultations:
  • 12 consults, now paid by scheme
  • Nuchal translucency or Non-Invasive Prenatal Test, now paid by scheme
  • Up to R5,000 for registered devices (breast pumps, etc) with 25% co-payment
  • Certain blood tests, now paid by scheme
  • Five pre- or postnatal classes with registered nurse, now paid by scheme
  • 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):
Executive
2017 v 2018 benefits Gap benefits Notes
Overall coverage (in and out of hospital):
  • Unlimited, subject to sublimit below. After the first R400,000, a 20% co-payment applies for non-PMB cancers
  • All cancer-related treatments are covered at 100% scheme rate
  • Specialised medicine and technology, defined list: R200,000 per person with a 20% co-payment
  • 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
All oncology benefits are assessed on a case-by-case basis, and are subject to protocols, preferred providers and scheme rules. Benefit covers out-of-hospital treatment too, like chemotherapy.

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DENTISTRY:
Executive
2017 v 2018 benefits Gap benefits Notes
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 at100% scheme rate and 300% scheme rate for specialists.
Out-of-hospital:
  • Standard dentistry: from day-to-day benefit
  • Specialised dentistry: from day-to-day benefit, limited to R26,200 per person. This limit includes claims for orthognathic surgery, dental appliances and their placements
Fusion Gap:
  • Up to 800% scheme rate for specialists and 700% 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:
  • 500% 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

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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

OR

Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family

MEDICATION:
Executive
2017 v 2018 benefits Gap benefits Notes
Chronic:
  • No benefit

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Acute (presrcibed) medication:
  • Schedule 3 and above
  • Paid from day-to-day benefit, up to the limits below
Main M1 M2 M3+
R35,400 R41,500 R47,500 R53,600
  • 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:
  • To be confirmed
  • No benefit
On Discharge:
  • See "Acute Medicine" benefit
  • No benefit
Biological:
  • For a defined list of latest treatments, limited to R200,000 per person, with a 20% co-payment
Fusion Gap:
  • If part of oncology treatment, gap will cover the co-payment

Discovery Gap:
  • Up to R100,000 for Oncology co-payments if oncology threshold has been reached

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OPTOMETRY:
Executive
2017 v 2018 benefits Gap benefits Notes
Optometry:
  • R7,300 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:
Executive
2017 v 2018 benefits Gap benefits Notes
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

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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+
R21,200 R25,500 R29,800 R35,800
  • 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:
Executive
2017 v 2018 benefits Gap benefits Notes
General Appliances:
  • External appliances limited to R58,800 per family from day-to-day benefit
  • Cochlear implants: R214,500
  • No benefit

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1.1. Hearing Aids:
  • R23,700 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 $1 million per person for emergency costs while travelling outside South Africa, for a period of 90 days. Excludes pre-existing conditions.
  • $$ Second opinion from Cleveland Clinic: now paid for by scheme
  • R750,000 per person for international treatment not available in South Africa, with 20% co-payment
  • $$ R300,000 to cover voluntary in-hospital treatment outside South Africa. This is a new benefit.
  • No benefit
Other:
  • Internal nerve stimulators: R147,300
  • Trauma recovery: out-of-hospital claims related to certain traumatic events paid until the end of the year following the event
  • DNA Analysis: paid in full from day-to-day benefit or 50% from above threshold
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 policyholder was not at fault: Gap will provide all legal assistance, fully covered.

Discovery Gap:
  • Benefits for disability and dread disease pay out can be obtained from the Supplementary Gap

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WELLNESS/PREVENTATIVE BENEFITS:
Executive
2017 v 2018 benefits Gap benefits Notes
Flu vaccination:
  • Covered, for 65yrs+
  • No benefit

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Pneumonia vaccines:
  • -
  • No benefit
Back Rehabilitation Programme:
  • -
  • No benefit
Biometric Screening:
  • Covered
  • No benefit
Child Immunisation:
  • -
  • 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

OR

Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family

2017 v 2018 benefits Gap benefits Notes
Overal Limit: .
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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

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