The Illness Hospital Benefit Explained

The Illness Hospitalisation benefit covers you for hospital costs related to an illness.

There needs to be a diagnosis for procedures to be covered and they must be medically necessary. Elective surgery and admission for diagnostic purposes is not covered under this benefit.

There is up to R51,410 available to pay for hospital costs but it is broken up into specific amounts available per day that you spend in hospital (up to a maximum of 21 days).

Each admission day is calculated as 24 consecutive hours spent in hospital and each admission day follows on from the previous day.

For example, if you spend 72 hours in hospital then, with Level 2/3, you would have available:

• R10,600 for first 24 hours
• R6,890 for the second day
• R5,300 for the 3rd day
• adding up to R22,790 for the 3 days

With Level 3, you get specific cover for specific stated conditions:

• Hernia: R21,200
  
• Appendectomy: R37,100
• Gallbladder / Kidney Stones: R37,100
• Miscarriage: R10,600
• Hysterectomy: R47,700

These amounts are available to pay for treatment regardless of how many days are spent in hospital. These amounts are not in addition to the admission days.

For example, if you are admitted for kidney stone treatment and only spend 24 hours in hospital, then the R37,100 is available for treatment and not just the R10,600 for the 1st day in hospital.

Day Procedures are hospital procedures that can be done under one day, either in hospital or at a specialised Day Clinic. Examples include tonsillectomy and grommets.

Day procedures are covered under the benefit up to the limit of the 1st admission day on your chosen level.

The difference is simply whether you are admitted to hospital for an accident event or for some other illness related reason.

If it was an accident that resulted in hospital admission then the Accident Hospitalisation Benefit applies with the larger amounts available to pay for all medical costs related to the accident.

If it was not accident then the Illness Hospitalisation Benefit applies.

There is a 3 month waiting period for any events that fall under admission day cover.

The stated conditions (on level 3) have their own waiting period:

• 12 month waiting period for stated conditions
• 24 months waiting period for hysterectomy

Yes. In general, all hospital related claims need to be authorised first.

Authorisation is a simple procedure where the administrator and the hospital determine:

• if the procedure you need is covered by your policy
• if you have available amounts left over after previous claims

The authorisation procedure is described on the Claims page. We also have an article that explains how authorisation works with a health insurance.

No. Our health insurance product works with all major public and private hospitals, as well as day clinics.

This is because health insurance and medical aids work differently. We are not contracted to the hospitals for rates and tariffs, the underwriter guarantees the payment of the stated amounts in your benefit limits.

We have a helpful blog article that explains why the hospital does not need to recognise the health insurance product (unlike a medical aid).