Where can I get my membership card?

The Kaelo MyHealth App lets you view and download your digital membership card at any time. Digital cards provide the same benefits as plastic cards and help prevent fraud because they require login details.

To download the Kaelo MyHealth App, search for “Kaelo Health” in your app store. Register using your Policy Number, then select My Profile > Digital Card.

A plastic card is printed and dispatched after your first premium is paid. If you haven’t received it within 30 days, contact the call centre or email membership@kaelo.co.za. You can use your Benefits before receiving your card.

What is authorisation and when do I need it?

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

What do I do if a Benefit requires authorisation?

To access the Benefit, you’ll need an Authorisation number. Contact us on 0861 665 665 and a service consultant will assist.

Do I need Authorisation for Maternity Benefits?

No, you do not need Authorisation to access the Maternity Benefit which covers 2 x 2D 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. Authorisation may be required for the GP visit, subject to the limits on your chosen plan.

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.

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 document 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, starting from the first day of the month, prior written notice via email to membership@kaelo.co.za. This cancellation will not warrant a refund.

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.

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 membership@kaelo.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.

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.

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 membership@kaelo.co.za.

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.

Am I covered for overseas travel?

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

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 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:

Take a clear photo of the claim and submit it to us on the Kaelo Health Mobile App.
Download and complete the refund request form here and email your claim to refunds@kaelo.co.za together with:

1. A copy of your ID.
2. The account for which the request is being made including:
   • Date of service
   • Practice number
   • Tariff/ICD-10 codes
   • Amount claimed
3. Your receipt as proof of payment.
4. Any requests over R3 000.00 must include proof of banking details (stamped statement or confirmation letter).

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.
If the claim is sent to you by email, you can email the claim directly to claims@kaelo.co.za.
You can also send any claim-related queries to us at claims@kaelo.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.

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 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 document 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 healthescalations@kaelo.co.za where our Executive Office will assist. If you wish to speak to us, contact 0861 665 665. If you wish to submit your complaint to the Insurer, email Centriq’s Internal Complaints Department at complaints@centriq.co.za. If you are dissatisfied with the response from Kaelo Risk or Centriq Insurance Company Ltd, you may approach the National Financial Ombud Scheme South Africa NPC or the FAIS Ombud. This must be done within 180 days of being advised that your representations to Centriq’s Internal Complaints Department 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 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/.

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
• Pre-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

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.

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 and share it via WhatsApp, email, or MMS.

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 check my Benefits?

In the App on the menu tab select “Benefits” or you can view them on your Policy document.

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.

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

To find a Prime Cure Network provider:

• Log in to the Mobile App and select “Find Doctor”
• Visit the Prime Cure website or the Mobile App
• Contact the call centre
• Email provider.loading@primecure.co.za and request a list of providers closest to you.

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.

What is my Doctor (GP) Benefit?

On the MyHealth Plus plan the Doctor (GP) Benefit is unlimited. You are required to get Authorisation for 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 yearPer year and you are required to get Authorisation for your doctor visits from the 3^rd consultation, by calling our call centre.

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

Use Prime Cure Network providers (GP, dentist, optometrist, etc.) to avoid out-of-pocket payments. On the MyHealth Plus plan, you have one out-of-network GP visit per Insured Party per year (maximum two per family per year), up to R1 100 per visit. You must get Authorisation before the visit.

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 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 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 driver’s 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.

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

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

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

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

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) and on the MyHealth Vital plan, you have two (2) per Insured Party per year. On the MyHealth Plus plan, you have unlimited virtual consultations Per Insured Party per year.

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.

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

A dispensing provider is a doctor (GP) who 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, as dispensing doctors (GPs) 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.

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 use a non-network Doctor (GP)?

You may only visit a non-Prime Cure Network GP if you are on the MyHealth Plus plan. Insured Parties are limited to one out-of-network visit per Insured Party per year (maximum two per family per year), paid up to R1,100 per visit.

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.

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 year.

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

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.

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.

Can I go to any pharmacy?

You must use a Prime Cure Network pharmacy. If you use a non-network pharmacy, your medicine will not be covered. All Dis-Chem, Pick n Pay, and Clicks pharmacies are part of the Prime Cure Network. To find a network pharmacy near you, use the Kaelo Health App or visit the Prime Cure website.

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 KaeloHealth App.

Can the pharmacy deliver my medications?

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

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.

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 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 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 document for detailed benefits on the Chronic Conditions covered under your specific plan.

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 can obtain a Chronic Medicine Benefit Application Form from your Prime Cure Network Doctor (GP), or from the Prime Cure website at primecure.co.za by navigating to Policyholders/Members > Member Forms > CDL Chronic Application Form
• Your doctor must complete the form and email it to pcauth@mediscor.co.za

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.

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 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  Network pharmacy. Please refer to your Policy document for the Benefit limits that apply to your specific plan.

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.

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 eight visits. Please refer to your Policy Document 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 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.

Can I go to any Dentist?

No, the Basic Dentistry Benefit is only covered if you go to a Prime Cure Network provider. 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 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, Emergency Treatment for pain and sepsis is limited to one after-hours visit per family per year. You may need to pay upfront; we will reimburse up to R800 per 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.

What is my optometry Benefit?

On the MyHealth Core and MyHealth Plus plans, you can visit a Prime Cure Network optometrist once a year for an eye test and get 1 pair of glasses every 24 months. You must use a Network optometrist; otherwise the account will be for your own cost. You are entitled to one set of clear CR39 single-vision or clear CR39 bifocal glasses every 24 months (subject to qualifying norms).

You must choose frames from the Prime Cure selection. If you choose frames outside the Prime Cure range on the MyHealth Core and MyHealth Vital plans , you will pay the difference. On MyHealth Plus, frames outside the Prime Cure selection are covered up to R600; you will pay the difference. Tinting and contact lenses are not covered.

What is the Specialist Benefit?

This Benefit is only available on the MyHealth Plus plan. You can visit a Specialist once a year; for families, up to two visits per year are allowed. You must pay for the Specialist consultation (and any related medication, blood tests, or X-rays) upfront and then submit a claim for reimbursement. We cover up to R2 000 per visit, subject to plan limits and Authorisation requirements. See the Claims section for how to request a refund.

How do I access the Specialist Benefit?

The Specialist Benefit is only available on the MyHealth Plus plan. You must get Authorisation before the visit. Contact the call centre or email authorisation@kaelo.co.za to get an authorisation.

You may need to pay upfront and claim back. Ensure the Authorisation number is recorded on the account to avoid rejection.

What is required to request Specialist authorisation?

Contact the call centre or email authorisation@kaelo.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.

Authorisation is valid for one month. Most Specialists are not contracted, so you may need to pay upfront and claim back from Prime Cure. Any amount above the agreed rate is for the Policyholder’s account.

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@kaelo.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 a 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 if I require blood tests or X-rays?

Pathology and radiology Benefits are subject to your doctor (GP) limits. If a Prime Cure Network GP refers you for basic blood tests, X-rays, or soft-tissue ultrasounds that are on the approved list, we will pay the account.

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 or soft tissue ultrasound request form to any radiologist.

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 is 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/

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 document for these.

What is considered a trauma and accident event?

“Accident” or “Accidental Injury”: an unintentional, unexpected, or unforeseen event that causes bodily injury and requires immediate medical treatment. To be covered, you must go to the emergency department immediately after an accidental injury.

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 Injury to an Insured when the Insured needs out-patient Treatment.

Please refer to your Policy document for a detailed breakdown of the Benefit and associated Authorisation requests. Services must be rendered at a Network emergency department. 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 in case of Accidental Injury to an Insured for in-patient Hospital Treatment. Please refer to your Policy document 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. All Treatment during this period must be Authorised by contacting the call centre. Services must be rendered at a Prime Cure Network 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 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 do I do in the event of a serious accident?

Call the call centre or NETCARE911 on 082 911 or 010 209 8364 (or use the emergency button in the App) for ambulance services. Netcare 911 will verify membership, arrange emergency transport to the nearest appropriate facility, and (if required) issue a Guarantee of Payment (GOP) for the hospital emergency department visit. If a GOP is issued after hours, contact us on 0861 665 665 within 72 hours to obtain an Authorisation number for the visit.

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 plan.

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

 Call the call centre, use the website, or use the Mobile App to locate a Prime Cure Network Healthcare Provider or the nearest out-patient facility that accepts a Guarantee of Payment (some facilities only accept cash). If you can’t get through, your call may be redirected to Netcare 911 for assistance. Even if you self-drive to a hospital emergency department, it’s important to call so your Policy can be validated (Policy number or ID/passport number).

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 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 plan.

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 emergency department.

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 NETCARE911 to request a Guarantee of Payment (GOP) once you have been transported to the closest appropriate facility.

What is Better Rewards?

Better Rewards is the Dis-Chem rewards programme available to Kaelo policyholders as part of their Lifestyle Benefits which may be selected at an additional fee.

How do I qualify for Better Rewards?

You need to be a Kaelo policyholder with Lifestyle Benefits and a Dis-Chem Better Rewards member. The 20% discount is automatically applied at the tills when scanning your Dis-Chem Better Rewards card or when making a purchase from the Dis-Chem Online store.

What are the benefits of Better Rewards?

The Better 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 a Better Rewards product is already on promotion or discount, the Policyholder will receive both discounts. There is also an opportunity to boost the discount with a 5% Pharmacy Boost and a 5% Capitec Boost. T&Cs Apply.

Can my dependants access Better Rewards?

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

How do I redeem my Better Rewards?

To redeem your Better Rewards discount, swipe or scan your physical or digital Dis-Chem Better Rewards card at the tills when paying for your purchases in-store or online when logged into your Dis-Chem online profile.

Can I redeem Better Rewards with my policyholder card?

No, Better Rewards cannot be accessed by presenting the Kaelo Health digital card, this card is only used for Prime Cure Providers, Dispensary or Clinic services to access Policy Benefits (medication, consultations or healthcare services). You need to use your Better Rewards card.

Are there any waiting periods for Better Rewards?

No, Better Rewards are activated on the inception date of your Kaelo Policy and remain active as long as your Policy is in good standing.

Do Policyholders have to pay an additional cost for Better Rewards?

Better Rewards is part of Lifestyle Benefits, which may be selected at an additional fee.