Gap Cover FAQ’s

Are my dependants covered?

Dependants can be included in your policy if you apply for their cover and they meet the eligibility criteria for a dependant as noted in the policy.

Can shortfalls occur in any other way?

Yes, they can also occur if your medical scheme imposes co-payments or deductibles on certain procedures, e.g. MRI/CT scans or diagnostic scopes while in hospital.

Do all specialists charge more than the medical aid tariff?

A lot of them do and the charges vary from 1.5 times above what the medical scheme covers up to as much as 5 times more than the medical aid tariff.

How do I claim from my Gap Cover?

You can visit the website and either download a claim form or complete the online claim form.

How do these shortfalls occur?

They occur when your selected doctor or medical specialist charges more than what your medical aid pays for a procedure or specific code. This is called a ‘tariff’ shortfall.

How much is a co-payment or a deductible?

It all depends on your medical plan and on the type of procedure, but they range from around R2,000 up to as much as R15 000 per case.

How much is a tariff shortfall?

Tariff shortfalls vary according to the fees charged by your medical specialist and also the severity of the procedure. Typically, the shortfalls on minor procedures are several thousand rands and can be anywhere between twenty and forty thousand rands on large procedures.

How often does Gap Cover pay claims?

Gap Cover claims are processed daily and benefit payments payable to dependants are also made daily. Claims take 7 – 14 working days to finalise once all required documents are received.

If I would like to cancel, what is the notice period?

A minimum of 31 days’ notice is required in order to cancel your policy.

What is Gap Cover?

Gap Cover is a short-term insurance product that helps you cover certain cost shortfalls between what your medical provider charges and what your medical aid pays.

What supporting documents are required in order to claim from my Gap Cover?

Fully completed claim form, copy of the Doctor’s invoice, copy of the hospital account and a copy of your medical scheme statement showing the shortfall.

Will all my shortfalls be covered by Gap Cover?

The policy does contain some exclusions, please refer to your policy document for the detailed list.

Will I have any waiting periods?

The waiting periods are as follows:

3 month general waiting period
12 month condition-specific waiting period

If proof of previous cover is provided, the waiting periods will be reviewed and removed.

Medical Insurance Product FAQ’s

Dentistry

Can I go to any Dentist?

No, the Basic Dentistry Benefit is only covered if you go to a Prime Cure Network provider. Pre-authorisation is required for procedures exceeding certain limits. Please view your Policy document for a detailed breakdown of the Dentistry Benefits and limits that apply to your chosen plan.

How do I access my Basic Dentistry Benefits?

The Dental Benefit is only covered when making use of a Prime Cure Network Dentist. Each person on the Policy can go to a dentist in the Prime Cure Network for one dental check-up and one cleaning per year. It includes fluoride Treatment for children under 12 years. You also have cover for up to four dental (mouth) X-rays per Family per year and unlimited cover for repairs to your teeth, called composite fillings, or to have teeth taken out. You must get Pre-authorisation by calling Prime Cure on 0861 665 665 before the visit if you need repairs to four or more teeth (including fillings) or if you need to take out four or more teeth (extractions) per person per year. If you need emergency dentistry for pain and sepsis (infection), you have unlimited cover for root canal treatment, subject to a list of approved codes.

What do I do if I require dental treatment over a weekend or after hours?

Weekend or after-hours dentistry is not covered on the MyHealth Core and MyHealth Vital plans. On the MyHealth Plus plan but this is limited to one visit per Family per year and only covers emergency Treatment for pain and sepsis. When you go to the dentist, they will charge you the actual cost, and We will cover up to R800 for the visit.

To make sure the visit is covered, you need to authorise the visit by calling Prime Cure on 0861 665 665 or use the Kaelo MyHealth app to authorise the visit within 72 hours of the visit. You will need to pay the dentist and submit your claim to us for a refund. We will pay the claim at cost, up to the limit of R800.

extra

Are there any waiting periods?

No, the extra benefit is activated on the inception date of your Kaelo Health Policy and remains active as long as your Policy is in good standing.

Can I redeem rewards with my digital membership card?

No, extra cannot be accessed by presenting the Kaelo Health digital membership card. The Kaelo Health digital membership card is only used for Dispensary and Clinic services to access Policy Benefits (medication, consultations or healthcare services).

Can my dependants access extra?

No, the extra benefit is only available to the main Policyholder.

Do Policyholders have to pay an additional cost for extra?

extra is part of Lifestyle Benefits which may be selected at an additional fee.

For a list of qualifying products and more information visit: https://www.dischem.co.za/health-insurance/extra-by-dis-chem

How do I qualify for extra?

You need to be a Kaelo Health Policyholder and a Dis-Chem Benefit cardholder. The 20% discount is automatically applied at the tills when swiping your Dis-Chem Benefit card or when making a purchase from the Dis-Chem Online store.

How do I redeem my extra rewards?

To redeem the 20% extra discount, swipe or scan your physical or digital Dis-Chem Benefit card at the tills when paying for your purchase in-store or be logged into your Dis-Chem online profile (linked to your Dis-Chem Benefit profile) on the Dis-Chem website.

What are the benefits of extra?

This rewards programme gives Policyholders access to a 20% discount on a basket of healthy and essential products purchased from Dis-Chem stores and online. If an extra product is already on promotion or discount, the Policyholder will receive both discounts (excluding Bonus Buy promotions, for example 2 + 1 Cheapest free etc). Customers that qualify for discounts through rewards programmes that Dis-Chem participates in will continue to receive those benefits and discounts.

What is extra?

extra is a rewards programme available on Kaelo Health insurance products , as part of Lifestyle Benefits which may be selected at an additional fee. Kaelo Health Policyholders can make healthy choices through a 20% discount on a basket of healthy and essential products.

General

Can anyone join Kaelo Health?

If you are living in South Africa and meet the employment or financial requirements, you can join. You will need to provide a valid ID or Passport and proof of banking details.

Can I get health insurance for someone else, like my home assistance staff or family in my care?

Yes, you can get health insurance for household employees or family members that are in your care. Fill out your details here and a broker will contact you back to assist you.

Do you issue Tax Certificates?

No, insurance products do not have any tax benefits to the individual taxpayer.

What are the call centre operating hours?

The call centre operates during the following hours: Monday to Friday: 08:00 to 17:00 and Saturday: 08:00 to 12:00. For after hour emergencies call NETCARE911 on 010 209 8364.

What are the Tax Benefits to the Employer?

An employer can deduct their share of the Kaelo Health Premium payment and receive corporate tax relief of 28% (or applicable corporate tax rate).

What is a waiting period and how does it work?

No waiting periods apply to Accident Cover Policies.

On  Day-to-Day benefits, a waiting period is a period in which a Policyholder is not entitled to claim any or certain Policy Benefits under a Policy. This is usually the period after taking out a new Policy. This protects the insurer from individuals who join, claim a large amount and then cancel their cover.

There is a one-month General Waiting Period on new policies where no claims will be covered. We will cover these visits even when you are in a general waiting period, so you will be able to have a consultation with a doctor, if needed:

  • Nurse consultations in a Dis-Chem and Clicks clinic
  • Virtual consultations through Kaelo’s virtual clinic platform
  • Virtual consultation in a Dis-Chem clinic on referral from a nurse.

There is a six-months Condition-Specific Waiting Period for chronic medication, for HIV and type 2 diabetes mellitus. A Condition-Specific Waiting Period means Chronic Medicine for these two Chronic Conditions that already existed before the Policy was taken out won’t be covered for six months from the Start Date of the Policy.

Newborns or a Spouse added to the Policy within 90 days of birth or marriage won’t have any waiting periods. Dependants added within 90 days of the Policy Start Date also won’t have waiting periods.

No general waiting period will apply to a newborn child or eligible spouse if you add them to your policy within 90 days from their birth or marriage date. No general waiting period will apply to an eligible child if you add them within 90 days from the date of activation of the Policy.

To add a newborn child or spouse to your policy, email dischemhealth.co.za. Premiums will be payable from the birth or marriage date. The insurer reserves the right to change the application of waiting periods by giving notice 31 days before such a change

We will remove the waiting periods on a Policy if you can prove that you had previous medical insurance or medical aid cover for a certain period.

  • The General Waiting Period will be waived if you can provide proof that you had at least three months of previous cover with no more than a two-month break before taking out this Policy.
  • The Condition-Specific Waiting Period will be waived if you can provide proof that you had at least six months of previous cover with no more than a two-month break before taking out this Policy.

It’s important to provide proof of previous cover to Kaelo before the Start Date of your Policy. If you don’t submit the proof of cover in time, there will be a delay in finalising your claims. You will then need to manually submit these claims for payment within 120 days from the date of service.

What is the difference between medical aid and our medical insurance products?

Medical Aid: Medical aids are governed by the Medical Schemes Act. This means that medical schemes must cover the costs related to a diagnosis and treatment of emergency medical conditions and Prescribed Minimum Benefits, which includes a limited set of 271 medical conditions and 27 chronic conditions. Medical schemes will usually cover both planned and emergency treatment in Hospital.

Some medical aid plans only cover in-hospital care whereas more comprehensive medical aid plans will cover the cost of day-to-day medical costs and care in hospital.

Medical/Health Insurance and/or Accident Cover: Health insurance products are exempted under the Medical Schemes Act to be provided by insurers. Health Insurance does not have to include cover for Prescribed Minimum Benefits, but our Kaelo Health Day-to-Day Cover options do cover chronic medicine for a defined list of chronic conditions as well as day-to-day medical expenses, depending on your chosen plan.

The Kaelo Health Accident Cover, which can be taken together with our Day-to-Day  Cover product or as a standalone product, provides cover for stabilisation, transportation, and treatment in hospital for medical emergencies related to accidents or illness, depending on your buy-up option. However, it will not cover the costs of a planned Hospital admission.

Medical aids generally have very high or no annual limits on hospitalisation.

The Kaelo Health Accident cover has a set limit for emergency hospitalisation, stabilisation and illness. The annual limit depends on the option you choose and this has an impact on the price of the product.

Medical aids typically start at a much higher price than medical insurance because of the unlimited cover they have to provide for Prescribed Minimum Benefit conditions and hospital care.

Medical insurance products are usually cheaper than medical aid plans because of the specific cover that they provide. Our Kaelo Health Day-to-Day Cover options provide cover for day-to-day expenses, like doctor visits, dentist visits and medicine, but various limits apply in accordance with your chosen plan.

Hospital Emergency & Accident Cover

Is the cost of the ambulance service covered?

Yes, in the event of a valid local emergency or serious accident, you or the Hospital can contact Netcare 911 to request a Guarantee of Payment (GOP) once you have been transported to the closest appropriate facility.

Is there hospital cover for a medical condition?

We do not cover Hospital admissions unless the cause of the incident is related to trauma or an accident.

However, you can select the Medical Emergency Illness Cover Buy-Up Option as an add-on to the Accident Cover. The Medical Emergency Illness Cover Buy-Up Option provides access to quality private health insurance should you or your Family have a Medical Emergency event due to Illness. There are 13 qualifying conditions that are covered. Please refer to your policy wording for these.

What do I do in the event of a minor accident?

Call the call centre or visit the website or Mobile App to locate a Prime Cure Network Healthcare Provider or the nearest out-patient facility that accepts a Guarantee of Payment, as some out-patient facilities only accept cash.
If after hours, call Netcare 911 on 082 911 or 010 209 8364. Netcare 911 will arrange the Guarantee of Payment with the out-patient facility (casualty) and will send the Guarantee of Payment. We will create an authorisation number within business working hours and then settle the account directly with the outpatient facility, subject to the Benefit limitations of your specific plan. The patient must please ensure that they have their membership card and ID for verification purposes.

What do I do in the event of a serious accident?

Call the call centre or Netcare 911 on 082 911 or 010 209 8364 or hit the emergency button in the Mobile App. If you are incapacitated and unable to call Netcare 911 yourself, a family member can call on your behalf to request an authorisation. Netcare 911 will verify the membership of the person in need of help, whether it be the Policyholder or a Dependant. They will assist the patient with advice and emergency transportation to the nearest in-patient Hospital facility. They will issue the Hospital with a Guarantee of Payment and the Insured Party will be admitted for Treatment. We will create an authorisation number within business working hours and then settle the account directly with the Hospital, subject to the Benefit limitations of your chosen plan.

What does emergency stabilisation mean?

It is the immediate Treatment administered to a person for a Medical Emergency condition to stabilise the patient before they are transferred to a facility for further management e.g. Being treated for a heart attack at the scene of the accident by Netcare 911 before being transported to the appropriate Hospital. Subject to the Benefit limitations of your chosen plan.

What is an emergency casualty department?

An emergency department, also known as an accident and emergency department, emergency room (ER) or casualty department, is a medical Treatment facility specialising in emergency Treatment of patients who arrive without a prior appointment; either by their own means or by that of an ambulance. The emergency department is usually found in a Hospital or other primary care centres. Due to the unplanned nature of patient attendance, the department must provide initial Treatment for a wide range of Illnesses and injuries, some of which may be life-threatening and require immediate medical attention.
A designated section of a Hospital where people who are severely injured in accidents or suddenly become ill and need urgent Treatment are assessed and treated.

What is an emergency?

An emergency medical condition means the sudden, and at the time unexpected onset of a life-threatening health condition that requires immediate medical Treatment, where failure to provide medical Treatment will result in serious impairment to bodily functions, or serious dysfunction of a bodily organ or part, and would place the person’s life in serious jeopardy. Examples include heart attacks, strokes.

What is considered a trauma and accident event?

“Accident” or “Accidental Harm”: means bodily injury caused by violent, unintentional, external and physical means. Examples include motor vehicle accidents, severe burns, exposure to poison that is not self-inflicted. Any injury or Treatment resulting from Accidental Harm. Treatment for an Accidental Event will be provided up to a maximum of 90 days calculated from the date of the Accidental Event, provided the Treatment and services have been authorised by calling the Prime Cure call centre and are directly related to the Accidental Event.

What is the casualty benefit if I have a trauma and accident event?

Emergency out-patient services will be provided in the case of Accidental Harm to an Insured when the Insured needs out-patient Treatment and is transported to the relevant Hospital by Netcare 911.

Please refer to your Policy Schedule for a detailed breakdown of the Benefit and associated authorisation requests. Netcare 911 will authorise the Benefit amounts to the relevant Hospital in the case of an accident (caused by an Accidental Event) services must be rendered at a Network Provider Hospital casualty. No Benefit is payable under this clause for services that are related to an Illness unless you’ve selected the Medical Emergency Illness Cover Buy-Up Option as an add-on.

Any Specialist or follow-up visits for medical cases are not covered under the Casualty Treatment Benefit.

What is the hospital benefit if I have a trauma and accident event?

Emergency in-patient services will be provided for in case of Accidental Harm to an Insured for in-patient Hospital Treatment. Please refer to your Policy Schedule for a detailed breakdown of the Benefit and associated authorisation requests. Authorisation must be obtained by contacting the call centre. If you are incapacitated and unable to authorise a hospital admission yourself, a family member, or the Hospital can call on your behalf to request an authorisation. The Benefit covers Treatment and services for a 90-day period calculated from the date of the Accidental Event. All Treatment during this period must be Pre-authorised by contacting the call centre. Services must be rendered at a Prime Cure Network provider Hospital. No Benefit is payable under this clause for services that are related to an Illness. Any Specialist or follow up visits will not be covered if not related to the Accidental Event.

What must I do if I require an ambulance?

In the event of an emergency or serious accident call NETCARE911 on 082 911 or 010 209 8364 and follow the voice prompts. Medical emergencies will be transported to a state facility and Trauma and Accident emergencies will be transported to a Prime Cure Network Hospital Casualty.

Medical Insurance Claims

Do I need to claim for Medical Insurance?

You shouldn’t need to claim for Medical Insurance. Provided you are using Prime Cure Network Providers, claims are paid directly to the provider on your behalf through your Policy. In most cases, you will need to present your physical or digital membership card and ID to the Prime Cure Network provider and they will submit the claim directly to us for processing and payment. To prevent claims from not being paid, first check that you have obtained the necessary Pre-authorisation for the visit, that you have gone to a Prime Cure Network provider as well as to make sure you haven’t already exceeded any Benefit limits on your Policy for the year. Some claims are not automatically paid to the treating provider. This includes:

  • Specialist visits (when applicable, depending on your chosen plan)
  • When you visit a non-Network Provider
  • If your provider insists you pay in cash

You can fill out a reimbursement form within 6 months from the date of Treatment to claim for the service, subject to the available Benefits and limits on your chosen plan.

How do I dispute a claim assessment?

A claim may be disputed by making representation to Kaelo or the Insurer indicated in the Disclosure Notice attached to the Policy wording within 90 days of receipt of the benefit/rejection letter. Kaelo or the Insurer is obligated to provide the Policyholder with feedback within 45 days.

The Policyholder should first aim to resolve their dispute with Kaelo before contacting the Insurer. Submit your concerns in writing to the Kaelo Risk Complaints Manager by emailing escalations@primecure.co.za where our Executive Office will assist you. Should you wish to speak to us, please contact us on 0861 665 665. Should you wish to submit your complaint to the Insurer, please submit this in writing to the Internal Complaints Department of Centriq, for the attention of Centriq Complaints Department using complaints@centriq.co.za. If you are dissatisfied with the response from Kaelo Risk or Centriq Insurance Company Ltd, you are entitled to approach the Ombudsman for Short-Term Insurance (OSTI) or the Ombudsman for Financial Service Providers (FAIS) external independent offices. This must be done within 180 days of being advised that your representations to the Internal Complaints Department of Centriq have been unsuccessful.

Finally, we remind you of the following policy condition: Our policy requires you to institute legal action within 180 (one hundred and eighty) days after the expiration of the 90 (ninety) day period referred to above, failing which you will forfeit your claim and no liability can arise in terms of such claim. To access our complaints process, visit our website at www.kaelo.co.za under the Contact menu item for more details.

How do I follow up on the status of a claim?

You can view claims received, processed and paid on the Mobile App.

How do I request a refund for a claim I paid?

If you have paid for the services provided, you can submit the claim in any of the following ways:

  1. Take a clear photo of the claim and submit it to us on the Kaelo Health Mobile App.
  2. Download and complete the refund request form here and email your claim to refunds@primecure.co.za together with:
    • A copy of your ID.
    • The account for which the request is being made including:
      • Date of service
      • Practice number
      • Tariff/ICD-10 codes
      • Amount claimed
    • Your receipt as proof of payment.
    • Any requests over R3 000.00 must be accompanied by proof of banking details (stamped statement or confirmation letter).
  3. Submit the claim via the Prime Cure website by completing the online form and submitting the required supporting documentation. The entire form must be completed for your refund to be processed.
  4. If the claim is sent to you by email, you can email the claim directly to correspondence@primecure.co.za.
  5. You can also send any claim-related queries to us at correspondence@primecure.co.za.

Your refund will be processed within 14 days of receipt of all the required information. Where no proof of banking details have been supplied, Kaelo will not be held responsible for any payment made to the incorrect account.

Nurse and Wellness Clinic Based Care

How do nurse consultations work?

You can consult with a nurse at a participating Clicks or Dis-Chem pharmacy clinic. In many practices, nurses can provide scripts for minor ailments for up to schedule 2 medications. Please refer to your policy document for the wellness clinic limits that apply to your specific plan.

Is there a limit to nurse consultations?

Yes, you have 8 visits. Please refer to your Policy Schedule for the detailed Benefits and limits that are applicable to your specific plan. You can use your Over-the-Counter (OTC) Benefit if the nurse suggests OTC Medicine.

What is the Clinic Visit Benefit?

You have eight visits to a nurse in a Dis-Chem or Clicks clinic for a range of needs including:

  • Coughs, colds, flu, asthma, skin rashes, allergies, nebulisation and minor wound care
  • Baby weigh-ins and check-ups
  • Blood glucose and blood pressure monitoring
  • Flu vaccinations (see Flu Vaccination for details).

You can use your Over-the-Counter (OTC) Medicine Benefit for medicine that the nurse recommends you take, as long as the medicine is on the Medicine List.

What is the Screening Benefit?

We will pay for two health check-ups and an extra two HIV tests per person every year at either Clicks or Dis-Chem clinics. During these check-ups, the nurse will measure your height, weight and body mass index (BMI). They will also check your blood glucose (blood sugar), blood pressure, cholesterol levels and do an optional

HIV test. To find a clinic closest to you, visit the Prime Cure Find a Provider page at www.primecure.co.za.

Optometry

What is my optometry Benefit?

On the MyHealth Core and MyHealth Plus plans, you can visit a Prime Cure Network optometrist once every 24 months. Failure to visit a network optometrist will result in the account being your responsibility. You are entitled to one set of clear CR39 single vison or clear CR39 bi-focal glasses every 24 months. In order to qualify for glasses, your eye examination results must meet the qualifying norms.

You will need to choose frames from the Prime Cure selection of frames. On the MyHealth Core and MyHealth Vital plans, if you choose frames that are not in the Prime Cure range, you will need to pay the difference. On the MyHealth Plus plans If you choose a frame which is not in the Prime Cure selection, your frame will be covered up to R600 and you will need to pay the difference in cost. We do not cover tinting or contact lenses.

Pharmacy and Medicine

Can I get medication without a script from a Doctor (GP)?

Yes, you can consult with a pharmacist or nurse at an approved pharmacy, and they can suggest Over-the-Counter (OTC) Medication (medicine which does not require a script) for minor ailments. OTC Medication must be on the OTC Formulary and is limited to schedule 0-2 medicines, subject to your available limits on your chosen plan.

Can I go to any pharmacy?

You must go to a Prime Cure Network pharmacy to get your medicine. If you use a non-network pharmacy, your medicine will not be covered. All Dis-Chem, Pick n Pay and Clicks pharmacies are approved on the Prime Cure Network. To find a pharmacy in the Prime Cure Network, you can visit the Prime Cure website or log in to the Mobile App.

Can the pharmacy deliver my medications?

Yes, some pharmacies do offer delivery services. You can arrange with your selected pharmacy.

How do I find an approved pharmacy clinic?

All Dis-Chem and Clicks pharmacies are approved on the Prime Cure Network. To find a network pharmacy near you, visit the Prime Cure website or the Mobile App.

My dispensing provider did not provide me with enough medication?

As per legislation, a consultation is confidential and between a Doctor (GP) and patient. The Doctor (GP) will use their discretion to determine the correct dosage (how much medicine) to prescribe or provide to the patient. It is best to consult with your Doctor (GP) if you need more medication.

What is a Medicine List (Formulary)?

A formulary is an approved list of medicine covered by our policies. The Policyholder can normally find both generic and brand-name medication on the formulary. Visit this link to view the Medicine, Dental and Highly Active Antiretroviral Therapy (HAART) Formularies. Formulary prescription medication is chosen for its cost, effectiveness, and safety. Medication that is not on the formulary will not be covered and will be paid for by the Policyholder.

What is Chronic Medicine?

A Chronic Condition is a disease that lasts three months or longer and generally cannot be prevented by vaccines or cured by medication. A Chronic Condition also doesn’t disappear after a short course of medicine. A Chronic Condition can be treated by medicine that will likely be taken for a lifetime to manage the condition. Chronic Medicine is prescribed by a medical practitioner for an uninterrupted period longer than three months. Please refer to your Policy Schedule and Policy wording for detailed benefits on the Chronic Conditions covered under your specific plan.

What is Over the Counter (OTC) Medicine?

Over the Counter (OTC) Medicine is medication received or advised by a pharmacist and is for the Treatment of minor Illnesses. OTC Medicine is limited to the Prime Cure Medicine Formulary. Medication must be dispensed by a Prime Cure contracted network pharmacy. Please refer to your policy document for the Benefit limits that apply to your specific plan.

What is Scripted (Acute) Medicine?

Scripted Medicine is medicine that is used for diseases or conditions that have a rapid onset, severe symptoms and/or only need a short course of medicinal Treatment. Scripted Medicine must be prescribed by a Prime Cure Network Doctor (GP). Only medication on our Acute Formulary (medicine list) will be covered. Scripted Medicine must be provided by either a dispensing Prime Cure Network Doctor (GP), or a non-dispensing Doctor (GP) will give you a script to take to a Prime Cure Network pharmacy.

What is the Chronic Medicine Benefit?

Chronic Medicine will be covered in full, at 100% of the Agreed Rate if:

  • The prescribed medication forms part of the approved Chronic Medication Formulary (medicine list).
  • You have registered for Chronic Medicine with a Prime Cure Network Healthcare Provider.

Chronic Medicine is unlimited according to the Prime Cure Medicine Formulary for an approved list of Chronic Conditions. To view the full list of qualifying conditions for your specific plan, please visit your Policy document. You must ensure you have registered your condition with us by completing a Chronic Medicine Benefit Application Form with your treating Prime Cure Network Doctor and that your treatment is managed in line with the Prime Cure treatment guidelines.

To register for this Benefit:

You must get your medication from a Prime Cure Network pharmacy.

What is the process for applying for chronic medication?

All Chronic Medicine is subject to a registration process by your treating Prime Cure Network Doctor (GP). After the Doctor (GP) has diagnosed you with a Chronic Illness, they will register your Chronic Medicine by emailing a completed Chronic Medicine Benefit Application Form, copy of the prescription and if necessary, supporting documents to preauth@mediscor.co.za for Chronic Medicine or HIVDMP@primecure.co.za for HIV registration.

All Chronic Medicine needs to be registered from the first script. Some medication may require additional information, like laboratory test results for the medication to be approved. Prime Cure Network Doctors (GPs) are aware of the requirements.

Where can I get my Chronic Medicine?

Once your Chronic Medicine has been approved, you may collect it from any Prime Cure Network pharmacy.

Policy Holder

Am I covered for overseas travel?

No, international cover is not provided. Cover is limited to South Africa only.

Do I need authorisation for Maternity Benefits?

No, you do not need Pre-authorisation to access the Maternity Benefit which covers 2x2D ultrasound scans per Insured Party Per Pregnancy. This can be provided by either a Prime Cure Network GP or a Prime Cure Network radiologist, when referred by a Prime Cure Network GP. Pre-authorisation may be required for the GP visit, subject to the limits on your chosen plan.

How is the cover cancelled?

If you decide that the cover provided by a new Policy does not suit your needs and no Benefit has yet been claimed, you have 14 days from when you receive the  Policy to cancel the Policy in writing and any Premiums that have been collected before then, will be refunded within 31 days after your cancellation notice is received.

After the 14-day period, you may cancel your cover at any time, by giving 31 days prior written notice via email to applications@primecure.co.za.

The Insurer may alter the Benefits or the basis upon which Benefits are calculated under this Policy by giving 31 days written notice thereof. Cover or services provided will only be valid if the Treatment or service was provided prior to the Termination Date. In the event that any fraudulent act is committed by any Insured Party, the Insurer reserves the right to immediately cancel this cover and/or institute legal proceedings against the relevant party to recover any losses. Premiums are payable up to and including the Termination Date.

My debit order didn’t go through, what should I do?

Please contact your broker or contact the call centre on 0861 665 665 or email billing@kaelo.co.za.

What do I do if a Benefit requires Pre-authorisation?

To access the Benefit, you will require a Pre-authorisation number. You can contact us on 087 109 0992 to obtain Pre-authorisation and one of our service consultants will assist you.

What happens if the Premium payer does not pay my Premium on time?

If the Premium is not paid on the payment date, you have a 30-day grace period after which we will automatically deduct the Premium from the same account to ensure continuous cover. If this Premium is also not paid, you will unfortunately no longer have any cover for the period that was not paid for.

What is an exclusion?

An exclusion refers to the list of services, conditions and events which are not covered on the Policy. Please refer to your Policy document for more information about the exclusions on your chosen plan.

What is Pre-authorisation and when do I need it?

There are times when you are required to get Pre-authorisation before using a Benefit, to avoid a claim not being paid. Please check your Policy Schedule to understand which Benefits require Pre-authorisation for your chosen plan.

What should I do if my contact details have changed?

Please inform your broker of any contact or address changes. You can also update your information in the Kaelo Health MyHealth App, contact the call centre on 0861 665 665 or email applications@primecure.co.za. It is very important to keep your details up to date so we can effectively communicate with you and ensure that we can assist you as fast as possible in the case of an emergency.

Where can I get my membership card?

The Kaelo MyHealth Mobile App allows you and your Dependants to log in and view your digital membership card at any time. You can also download a copy of your membership card directly from the app. Because digital membership cards offer all of the same benefits as a plastic card, but with an extra layer of security by requesting login details to view it, it also helps to prevent fraud.

To download the Kaelo MyHealth mobile app, go to your app store and search for Kaelo Health. Register using your Policy Number and then select My Profile > Digital Card to view and download your membership card.

Your membership card will also be printed and dispatched after your first Premium has been paid. If you have not received your card within 30 days after the first Premium is paid, you should contact our call centre or email MyHealthlettersandcards@kaelo.co.za. Your Policy Schedule will be emailed to you. You can use your Policy Schedule to access Benefits before receiving your membership card.

Will my Policy Premium be adjusted and if so, how frequently?

Our products are rated annually with adjustments taking effect on 1 January of every year, however, we do reserve the right to adjust the Premium with 31 days written notice. Adjustments are based on various factors including, but not limited to, loss ratio experience, medical tariff increases and inflation, changes in the group demographic profile and Benefit changes.

Prime Cure Network

How do I find a Prime Cure Network provider – Doctor/dentist /optometrist etc?

To find a Prime Cure Network provider:

What is the Prime Cure Network?

Prime Cure is an accredited managed healthcare organisation providing health care via a network of more than 10 000 healthcare service providers including Doctors (GPs), dentists, pharmacists, optometrists, Specialists and private Hospitals.

What should I do if there is no network provider close to where I live or work?

Contact the call centre and we will try and find providers in the area. If we cannot reach one, we will make an arrangement to pay your Doctor up to a cost limit, subject to the available limits of your chosen plan. Alternatively, you can substitute your Doctor (GP) visits with a virtual consultation. You can book a virtual consultation through the Mobile App or our website.

Private Doctors (GPs)

Can a dispensing provider issue a script?

A dispensing provider may issue a script if they recommend medicine that is not kept in their rooms. These medicines are usually a higher schedule medicine and will not be covered. Please note that if your Healthcare Provider is a dispensing Doctor (GP), they are paid for services that include the consultation and prescribed medicine on the approved Prime Cure Formulary (medicine list). Go to this link to see the approved formulary: https://www.primecure.co.za/medicine-management/

Can I go to any Doctor (GP), dentist or optometrist?

You need to go to a Prime Cure Network Healthcare Provider (GP, dentist etc) to avoid any unnecessary out-of-pocket payments. However, if you are on the MyHealth Plus plan, you have one visit to a non-Prime Cure Network Doctor (GP) per Insured Party Per Annum, with a limit of two non-Prime Cure Network visits per Family Per Annum. You are required to get authorisation before you visit a non-Prime Cure Network Doctor, and out-of-network visits are limited to one visit Per Insured Party Per Annum, and up to two per Family Per Annum. Consultations are paid up to a limit of R1 100 per visit.

Can I use a non-network Doctor (GP)?

You may only visit a non-Prime Cure Network Doctor (GP) if you are on a MyHealth Plus plan. When visiting a non-network Doctor (GP), emergency medical facility or Prime Cure Network Doctor (GP) after hours, Insured Parties are limited to one visit per Insured Party Per Annum, up to a maximum of two visits per Family Per Annum, and paid up to a limit of R 1100.

As the Doctor (GP) is not contracted, you may need to pay upfront and claim back from Prime Cure. Following the consultation, please contact Prime Cure within 72 hours to obtain an authorisation number and submit your claim and proof of payment. Failure to obtain an authorisation within 72 hours will result in the claim not being refunded by Prime Cure.

Do I need to get authorisation every time I consult with the Doctor (GP)?

You will need to obtain Pre-authorisation for Doctor (GP) visits, depending on your chosen plan. On the MyHealth Core and MyHealth Vital plans, you need to Pre-authorise your visits to a Prime Cure Network GP from the 3rd consultation Per Insured Party Per Annum.

On the MyHealth Plus plan, you will need to Pre-authorise your Prime Cure Network GP visits from the 4th consultation per Insured Party Per Annum.

Please refer to your Policy document for the detailed Benefits and limits that are applicable to your plan.

How do I access virtual consultations for Family, Legal and Financial Counselling?

If you have taken out a plan with Lifestyle Benefits , you have access to Family, Legal and Financial Counselling, with unlimited telephonic, virtual or face-to-face appointments.

With Kaelo Virtual Consultations, you will be able to see a Lifestyle Professional via video conferencing technology. In order to book a virtual consultation, you will need a computer or smartphone with video functionality as well as a working internet connection.
You can book your consultation by selecting the relevant product and completing a short form. Once we have your details, you will receive an invitation via SMS or email.

How do Virtual Clinic visits work?

In addition to Doctor (GP) visits, you have access to virtual consultations via the Virtual Clinic platform on the Mobile App or website. This Benefit provides access to virtual consultations with a Prime Cure Network Doctor (GP). Your available virtual consultations are subject to your chosen plan.

On the MyHealth Plus plan, you have unlimited virtual consultations per Insured Party, Per Annum.

On the MyHealth Core plan, you have four virtual consultations per Insured Party, Per Annum.

On the MyHealth Vital plan, you have two virtual consultations per Insured Party, Per Annum.

To book a virtual consultation online, log in to the Mobile App and under “My Benefits” select “Book a Virtual Consultation”, or book a consultation on the website
by selecting “Self-Service” and then “Virtual Consults”.

You can also contact the call centre on 0861 665 665 and request a virtual consultation.

What if my existing Doctor (GP) is not a Prime Cure Network provider?

You can submit a request to have your Doctor (GP) loaded onto the network. Call the call centre and ask for a provider request form. Fill out the form with your Doctor’s (GP) details and email the form to provider.loading@primecure.co.za. The network team will contact the Doctor (GP) and advise you whether the Doctor (GP) decided to join. Should they decline, then you will be referred to a nearby Prime Cure Network provider.

What is my Doctor (GP) Benefit?

On the MyHealth Plus plan the Doctor (GP) Benefit is unlimited. You are required to Pre-authorise your Doctor visits from the fourth consultation through a virtual consultation with the Virtual Clinic. On the MyHealth Core and MyHealth Vital plans, you are limited to four visits per Insured Party Per Annum and you are required to Pre-authorise your Doctor visits from the 3rd consultation, by calling our call centre.

What is required when visiting a Doctor (GP)?

Ensure your Doctor (GP) is a Prime Cure Network Doctor (GP) and that you have available Doctor (GP) visits and Pre-authorisation, depending on your chosen plan. When you visit a GP:

  • Take your membership card or use your digital membership card in the Mobile App, and your ID, passport or drivers licence with you. This will allow your Doctor (GP) to check that your membership is active and that you do have Benefits available.
  • Check with your Doctor (GP) that your Treatment or prescribed medicine is on our list of covered services.
  • Ensure your Premium payments are up to date.

What is the difference between a dispensing and non-dispensing provider?

A dispensing provider is a Doctor (GP) that can prescribe medicine from a list of approved medicines on our formulary (medicine list) and dispenses the medicine to you after your consultation. If the dispensing Doctor (GP) does not have the specific medicine that you require, they might give you a prescription to take to a pharmacy. The pharmacy will ask you to pay cash for the medicine , as dispensing Doctor’s (GP’s) are paid an additional fee to provide medicine directly to our Policyholders.

A non-dispensing provider will give you a prescription that you can take to a pharmacy to get your medicine. If the non-dispensing Doctor (GP) prescribes medicine that is not covered on our list of approved medicines on our formulary (medicine list), you will need to pay cash for the medicine at the pharmacy.

What should I do once I have reached my Doctor (GP) visit limit?

Your GP consultation limits depend on your chosen plan and option. Please refer to your Policy document for the detailed Benefits and limits that are applicable to your chosen plan.

If you have reached your GP visit limits for the year, or if you prefer to consult with a doctor from the comfort of your home, you can conveniently consult with a doctor through the Virtual Clinic. During your virtual consultation, the GP will ask you questions to understand your previous medical history, general health and current symptoms. They can also issue a script, if needed, that you can collect from a Prime Cure Network pharmacy.

On the MyHealth Core Plan you have four (4) Ask A Doctor consultations and on the MyHealth Vital plan, you have two (2) Ask A Doctor Consultations per Insured Party per Annum. On the MyHealth Plus plan, you have unlimited virtual consultations Per Insured Party Per Annum.

To book a virtual consultation, contact the call centre during office hours on 0861 665 665 and select Virtual Clinic, or speak to one of our agents to request a virtual consultation.

Specialists

How do I access the Specialist Benefit?

The Specialist Benefit is only available on the MyHealth Plus plan. You must get Pre-authorisation before the visit. Contact the call centre or email auth@primecure.co.za to get an authorisation. You can also send a query via the Mobile App or website relating to Specialist authorisation. The Specialist consult is paid at cost up a limit of R2000 per visit. The majority of Specialists are not contracted and will require you to pay upfront and claim back. The Pre-authorisation number should be recorded on the account for payment to avoid any claims being rejected.

How do I claim/request a refund for a specialist consultation?

You can submit the claim via the Prime Cure website or email the claim to refunds@primecure.co.za. You will need to submit:

  • A completed refund form.
  • A copy of your ID.
  • The Specialist account for which the request is being made.
  • Receipt to show proof of payment.
  • Proof of your banking details (either a bank stamped statement or confirmation letter).
  • Include the word refunds in the subject line of your email.

The refund will be processed within 14 days of receipt of all the required information and supporting documents. We will not be held responsible for any payments made to the incorrect account if no proof of banking details is supplied.

What is required to request Specialist authorisation?

Contact the call centre or email casemanager@primecure.co.za and supply the following information:

  • Name and surname of the Insured Party requiring the authorisation.
  • Your Policy number.
  • The name and practice number of the referring Doctor (GP) if applicable.
  • Name and practice number of the Specialist.
  • Banking details of the Specialist.
  • ICD-10 code or diagnosis from the Specialist if not supplied by a referring Doctor.

The authorisation is valid for one month. Most Specialists are not contracted and you will be required to pay upfront and then claim back from Prime Cure. Any account in excess of the Agreed Rate will be the responsibility of the Policyholder.

What is the Specialist Benefit?

This Benefit is only available on the MyHealth Plus plan. You can go to a Specialist once a year, and in the case of a Family, We will allow up to two visits per year. You will need to pay for the Specialist visit and any medicine, blood tests or X-rays that the Specialist sends you for upfront and then submit your claim/s to us for a refund. We will cover up to R2 000 for the Specialist visit and the associated costs. Refer to the Claims section on how to request a refund. Please refer to your Policy document for a detailed breakdown of the Benefit limits and associated authorisation needed.

X-rays and Blood Tests

Do I need a specific form for pathology/radiology test referrals?

Yes, please make sure that only the Prime Cure pathology/radiology form for tests/referrals are completed and given to you before going for these tests. All tests not listed on these forms are not covered and will be for the patient’s account. The applicable form must be completed by the referring Network Provider:

For radiology – https://www.primecure.co.za/radiology-request-form/
For pathology – https://www.primecure.co.za/pathology-request-form/

What if I require blood tests or X-rays?

The pathology and radiology Benefits are subject to the Doctor (GP) limits. If your Doctor (GP) needs to send you for basic blood tests, X-rays and soft tissue ultrasounds, we will pay the account if the Doctor (GP) is a Prime Cure Network Provider and the blood tests and or X-rays and or soft tissue ultrasounds, are on the approved cover list.

You must take the pathology request to a Prime Cure Network pathology lab. The following pathologists are contracted by Prime Cure:

  • Ampath Laboratories
  • Pathcare Laboratories
  • Lancet Laboratories
  • Lab 24

There is no cover for specialised radiology – MRI, PET Scans and CT Scans. You can take the X-rays and or soft tissue ultrasound request form to any radiologist.

App FAQ’s

AskNelson October Health App

How do I download / access October Health?

The October Health app is available on the Apple and Android app stores. Search for ‘October Health’ to download it and register for free.

Is October Health free to download?

October Health is free to download and use, but normal data service provider costs apply when using the app. There is also no cost involved in accessing the forest community and engaging with other users, joining peer- or expert-facilitated discussions, doing self-assessments, or using the personal progress tracking tools.

What is October Health?

October Health is an app that provides access to mental health support and resources, as well as an inclusive community of like-minded people, to help individuals dealing with any type of mental health challenge to manage their condition and achieve a life worth living.

MyHealth Mobile App

How do I access my Digital Membership Card?

On the menu tab of the App, select My Profile > Digital Card to view and download your membership card. You can save your digital card on your phone as well as share it via WhatsApp, email or MMS.

How do I access the Mobile App?

You can download the Kaelo MyHealth App from the Google Play, Apple or Huawei App Store or by visiting https://www.kaelo.co.za/apps/.

How do I check my Benefits?

In the App on the menu tab select “Benefits”. There you will be able to view your: Brochure, Policy, Disclosure and Renewal Notice or you can view them on your Policy document.

How do I locate Prime Cure Network doctors?

In the App on the menu tab select “Find Doctor”. The Mobile App will take you to the Prime Cure website where you can choose the type of Doctor you need and the area.

How do I reset my password?

To reset your password in the Mobile App, select the “Forgotten Password” button. A temporary password will be sent to you via the preferred communication you selected during app registration (SMS or email). Log in to the App using the temporary password to create a new password. If any of your details have changed, contact the call centre to update your profile. Please have your registration details with you.

What features are available on the App?

The Mobile App allows you to easily access important Policy documents and has many other useful features such as:

    • An emergency button for easy emergency assistance
    • Access to your membership details, digital membership card and membership certificate
    • A useful summary of your plan details and limits
    • A Benefit dashboard
    • Tracking of your Doctor (GP) visits and medication
    • Tracking claims received, processed and paid
    • Finding your closest Doctor (GP), dentist, or optometrist
    • Authorisation requests
    • Communication, Policy document and brochures
    • Logging queries for assistance
    • Book a virtual consultation
    • Contact details for any enquiries
    • Answers to frequently asked questions
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