Exclusions & Limitations

In terms of the SEDMED Rules (Annexure C), the following Exclusions and Limitations apply.

Unless otherwise provided for or decided by the Board, expenses incurred in connection with any of the following will not be paid by SEDMED.

EXCLUSIONS:

• 1.1 Subject to benefits payable in respect of the Prescribed Minimum Benefits (PMBs) all costs of whatsoever nature incurred for treatment of sickness conditions or injuries sustained by a member or a dependant and for which any other party is liable. The member is entitled to such benefits as would have applied under normal conditions, provided that on receipt of payment from another party in respect of medical expenses for which any other party is liable as mentioned above, the member will reimburse the scheme any money paid out in respect of this benefit by the Scheme.
• 1.2 All costs relating to infertility treatment and artificial insemination.
• 1.3 All costs in respect of injuries arising from participation in professional sport, speed contests and speed trials unless prior approval for participation has been obtained.
• 1.4 All costs for operations, medicines, treatment and procedures solely for cosmetic purposes.
• 1.5 Holidays for recuperative purposes.
• 1.6 Purchase of:
  • contraceptives and apparatus to prevent pregnancy;
  • tonics, slimming preparations and drugs as advertised to the public and/or other products which are normally available over the counter, such as health tonics/tablets etc. unless prescribed by a physician for a specific illness and time frame;
  • patent medicines and proprietary preparations;
  • applicators, toiletries and beauty preparations;
  • bandages, cotton wool, other consumable items and similar aids;
  • patented foods, including baby foods; and/or
  • household and biochemical remedies.
• 1.7 All costs in excess of the annual maximum benefit to which a member is entitled in terms of the Rules of the Scheme.
• 1.8 Charges for appointments which a member or dependant of a member fails to keep.
• 1.9 Costs for services rendered by:
  • persons not registered with a recognized professional body constituted in terms of an Act of Parliament; or
  • any institution, nursing home or similar institution except a state or provincial hospital not registered in terms of any law.

LIMITATION OF BENEFITS:

• 2.1 The maximum benefits to which a member and his dependants are entitled in any financial year are limited as set out in the Annexure B of the SEDMED Rules.
• 2.2 Members admitted to SEDMED during the course of a financial year are entitled to the benefits set out in the third column of Annexure B of the SEDMED Rules, with the maximum benefits being adjusted in proportion to the period of membership calculated from the date of admission to the end of the particular financial year.
• 2.3 In the absence of prior approval, benefits in respect of medicines obtained on a prescription are limited to one month's supply for every such prescription or repeat thereof.