|It’s a lazy Sunday afternoon. Simon, your 10-year old son, falls from the treehouse and suffers a fractured ankle. You rush him to the emergency room at your nearest hospital.|
Thank goodness you have a Stratum Benefits Gap Cover policy with Casualty Cover that refunds the amount that you pay from your own pocket, or that your medical aid pays from a day-to-day benefit or your medical savings account.
This means that even if your medical aid doesn’t provide a benefit for casualty events, we do! Now that’s value.
The below benefit limits apply subject to the Overall Policy Limit of R 165 000 per person per year, except on Access Optimiser Plus where the Overall Policy Limit is
R 165 000 per policy per year:
|Compact200 & Base – R 6 000|
Elite, Corporate Elite Plus & Corporate Elite – R 12 000
Co-Evolution – R 8 000
Access Optimiser Plus – R 2 000
CASUAL+Y COVER FOR ACCIDENTS
|The qualifying criteria for cover are as follows: the medical event must be due to an accident, which is defined as an event caused by physical impact resulting in physical injury; must require immediate treatment, which is defined as treatment required within 48-hours from the time of the accident; andtreatment must be provided at a registered medical facility, which can be a doctor’s room or emergency roomOur benefit covers insured persons of all ages for accident-related events.|
CASUAL+Y COVER FOR ILLNESS
|We provide cover for children when they need medical treatment due to an illness.|
The qualifying criteria for cover are as follows: the child dependant must be younger than 6;treatment must be provided at a registered casualty facility (emergency room) and not a doctor’s rooms; andtreatment must be provided after-hours, which is defined as Mondays to Fridaysbetween 18:00pm and 07:00am, and all-day Saturdays, Sundays and public holidays.
RELATED HEALTHCARE PROVIDERS’ ACCOUNTS
|We cover the accounts of all the medical services that form part of a casualty event:|
|Upfront casualty co-payments and facility fees;|
some medical aids require you to pay an upfront co-payment whilst some emergency rooms will require an upfront facility fee.
|Doctors’ and specialists’ consultations;|
consultation fee of the healthcare provider on duty.
|Basic and specialised radiology;|
e.g. x-ray of the fractured ankle.
e.g. any blood tests needed.
e.g. cast for the fractured ankle and surgical gloves.
|Medication received during the casualty event;|
e.g. pain medication received during the event, but not take home and/or prescription medication.
|External medical items that are required as a result of the casualty event; |
external medical items, such as a moon boot, must be provided at the registered medical facility during the initial casualty event.
|Return visits to a registered medical or casualty facility for follow-up treatment; |
return or follow-up visits are covered only when it’s required as a result of the initial accident-related casualty event.
EXAMPLE OF A RETURN VISIT
Simon was treated at a registered casualty facility for a fractured ankle.
If Simon sees a specialist and has x-rays taken 4 weeks after his fall to check the healing of his fractured ankle, we’ll cover the consultation and x-rays under Casualty Cover as the follow-up visit and x-rays are required as a result of the initial accident-related casualty event, subject to the benefit limit provided.
When you’re admitted to hospital for an accident for which you’ve been treated at a registered medical facility, the hospital admission becomes a new medical event and a return visit for follow-up treatment will not be considered under Casualty Cover.
WHEN CLAIMING, WE REQUIRE…
|• A fully completed Claim Form.|
• Medical or casualty facility account or hospital account indicating the ICD10 code.
The account is required to see if the event was due to an accident or not.
An S or T ICD10 code is used for accidental events. E.g. S22.2 fracture of the sternum.
• All the service providers’ accounts associated with the event.
• A Claims Transaction History (CTH) to determine if your medical aid paid an amount towards the casualty event from a hospital or risk benefit, as this amount is not claimable.
• Proof of payment if you’ve paid for the event yourself.
Contact Ginsburg Financial Services for more information.