Major Medical


All Major Medical Expenses are subject to pre-authorisation.

PRO-RATED BENEFITS

Benefit limits are usually allocated in calendar year cycles (from 1 January to 31 December) and is only applicable to the current year. Most benefits follow a one year cycle.
Benefit limits will be prorated should a member join during a year.
Ex Gratia and Additional Benefits
As an Employer-based restricted Medical Scheme, Imperialmed can lawfully grant ex gratia payments to its members. Ex gratia payments are defined as payments in addition to the registered rules and benefits of the Scheme and for purposes of clarity, Imperialmed will make a distinction between ex gratia payments and additional benefits.

  • 1 Hospitalisation - Private and Provincial
    a Accommodation in general ward, recovery room, intensive care unit or high care ward

    Subject to Pre-authorisation (0860 467 374)

    100%

    of Medical Scheme Rate

    b Theatre fees

    Subject to Pre-authorisation (0860 467 374)

    100%

    of Medical Scheme Rate

    c Medicines used in hospital/theatre

    Subject to Pre-authorisation (0860 467 374)

    100%

    of Medicine
    Price.

    A deductible of R1 000 applies if the following procedures are done in hospital:
    d Scopes
    - Arthroscopies
    - Gastro-intestinal endoscopies
        • Gastroscopies
        • Colonoscopies
        • Sigmoidoscopies
    - Urological scopes and cystoscopies
    - Gynaecological scopes
    - Biopsies
    - Minor dermatological procedures
    - Dental Procedures Refer to dental benefit for more details on in-hospital dentistry (item 19 of Major Medical)
    - Nail surgeries
    - Minor skin lesions
    - Vasectomies
    - Conservative neck and back procedures
    - Circumcisions - Dental Procedures

    100%

    of Medical Scheme Rate. A deductible will not apply if done in doctor's rooms. Services in rooms will be paid at 100% of Medical Scheme Rate, except for dental procedures, which are still paid as day-to-day dental benefit

    e Circumcision

    Deductible applies, see 1a) above

    R2 150 per beneficiary per annum
          Subject to Pre-authorisation (0860 467 374)

    100%

    of Medical Scheme Rate

    fDental Procedures

    Subject to Pre-authorisation (0860 467 374)

    100%

    of Medical Scheme Rate.

    • Dental benefits which can be done in the dentist's room will have a deductible of R1000 if done in hospital.
    • If done in the dentist's room, the payment will still be in accordance with the day-to-day limits and only at 85%

  • 2 Post-operational physiotherapy
    Physiotherapy after hip, knee and shoulder replacement surgery and spinal surgery only. Physiotherapy treatment after any other procedure will be paid from the Day-to-Day physiotherapy benefit limit.

    6 Weeks' Treatment
    Subject to Pre-authorisation (0860467374)
    As per clinical propotcols

    100%

    of Medical Scheme Rate

  • 3 GPs and Specialists
    For Prescribed Minimum Benefit Services rendered by a Specialist, the following rule applies: Rule 6.2.2 - The Scheme shall pay 100% of Scheme Tariff in respect of any in hospital
    services which are voluntarily obtained by a beneficiary from a service provider, other than a DSP, for a prescribed minimum benefit condition, other than medicine for a chronic condition.
    a Visits and consultations

    Subject to Pre-authorisation (0860 467 374)

    100%

    of Medical Scheme Rate

    b Surgical procedures and anaesthetics

    Subject to Pre-authorisation (0860 467 374)

    100%

    of Medical Scheme Rate

  • 4 Diagnostic Services
     
    a Radiology (X-rays) and pathology (in hospital)

    Subject to Pre-authorisation (0860 467 374)

    100%

    of Medical Scheme Rate

    b MRI, CT and radio-isotope scans (in and out of hospital)

    R17 220 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Medical Scheme Rate

    c Ultrasound scans (in and out of hospital)

    R4 620 per beneficiary per annum

    100%

    of Medical Scheme Rate

    d PET scans (in and out of hospital)

    R23 730 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Medical Scheme Rate

    e Sleep studies, diagnostic polysomnograms (in and out of hospital)

    Subject to pre-authorisation (0860467374)

    100%

    of Medical Scheme Rate

  • 5 To-take-out (TTO) Medicine

    Medicines dispensed on discharge from hospital will be covered under the Major Medical Expenses

    Subject to R440 per beneficiary per admission

    100%

    of Medicine Price

  • 6Out-patient Services
    Private and provincial hospitals


    • If the ICD10 code is for an emergency (indicating that it is a prescribed minimum benefit), the cost of the consultation, facility, procedure, related materials and medication is to be paid at 100% of cost from the Major Medical Expenses.
    • If the ICD10 code is not for an emergency (indicating that it is not a prescribed minimum benefit), the cost of the consultation, facility, procedure, related materials and medication is to be paid at 85% of Scheme Rate from the applicable day-to-day benefit limits.
    • The ICD-10 code is used to determine whether it is an emergency or non-emergency.
    • Emergencies are classified as prescribed minimum benefits and has to be covered in full.

    100%

    of Cost from Major Medical Expenses for an emergency; and

    85%

    of Scheme Rate for non-emergency

  • 7 Blood Transfusions

    In Hospital
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost

  • 8 Nursing Services, Sub-acute Care and Hospice Services
    Including medicines, dressings, ointments, etc

    Subject to Pre-authorisation (0860467374)

    100%

    of Medical Scheme Rate or Cost, whichever is the lesser

  • 9 Ambulance Services

    R8 720 per beneficiary per annum
    Subject to approval and Pre-authorisation by preferred provider (0860467374)
    Europ Assistance (0861 737 283)
    Emergency air ambulance not subject to the above limit.

    100%

    of Cost

  • 10 Internal Prostheses
    Including all accompanying temporary or permanent devices used to assist with the guidance, alignment or delivery of these internal prostheses and devices
    Patients may obtain pre-authorisation 10 (ten) working days prior to admission for a joint replacement or spinal fusion operation.
    Cardiac stents (including carrier)

    Subject to a limit of R24 330 per stent (maximum of three) per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Cardiac stents - drug eluting

    Subject to a limit of R26 530 per stent (total of three) per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Cardiac pacemakers

    Subject to a limit of R58 045 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Cardiac valves

    Subject to a limit of R36 150 per valve (limited to two) per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Cardiac pacemakers with defibrillator

    Subject to a limit of R94 500 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Aortic stents

    Subject to a limit of R94 290 per stent (including the delivery system), limited to one stent per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Carotid stents

    Limited to R15 700 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Detachable platinum coils

    Limited to R37 200 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Embolic protection devices

    Limited to R37 100 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Peripheral arterial stent grafts

    Limited to R32 380 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    EVAR (Endovascular repair)/Anaconda

    Subject to a limit of R63 000 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Hernia mesh

    Subject to a limit of R6 640 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Hernia mesh - umbilical repair

    Subject to a limit of R11 060 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Total hip replacement

    Subject to a limit of R50 030 per hip, including cement and antibiotics per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Total knee replacement

    Subject to a limit of R48 720 per knee, including cement and antibiotics per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Total shoulder replacement

    Subject to a limit of R43 910 per shoulder, including cement and antibiotics per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Spinal instrumentation

    Subject to a limit of R35 520 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Other approved spinal implantable devices and intervertebral discs

    Limited to R41 130 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Bone lengthening devices

    Limited to R33 400 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Neuro-stimulation/abalation devices for Parkinson's disease

    Limited to R35 600 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Vagal stimulator for intractable epilepsy

    Limited to R30 340 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Intraocular lenses

    Limited to R8 340 per lens per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

    Any other internal prostheses

    Subject to a limit of R42 160 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost
    PMBs not subject to sub-limits

    100%

    of Cost
    Non-PMBs subject to sub-limits

  • 11 Renal Dialysis
    Inclusive of all related costs

    Benefit is subject to the submission of a treatment plan by the treating Specialist to the Care Manager and approval of the treatment plan before treatment starts

    Subject to Pre-authorisation (0860467374)

    100%

    of the Negotiated Rate

  • 12 Organ Transplants
    a Hospital accommodation and surgically-related services and procedures

    Subject to Pre-authorisation (0860467374)
          PMBs covered in full, i.e. Heart, Kidney and Liver
          Non-PMBs covered at Medical Scheme Rate, i.e. Other Organs

    100%

    of Negotiated Rate

    b Heart, kidney and liver

    Including organ search (nationally only), harvesting and transportation. The benefit covers the donor if the recipient is an Imperialmed member

    Subject to Pre-authorisation (0860467374)
          Unlimited
          Other organs subject to limits in 12d) below

    100%

    of Cost

    c Corneal transplant

    Including organ search (nationally only)

    Subject to Pre-authorisation (0860467374)
          R15 800 per beneficiary per event

    100%

    of Cost

    d Other organs

    Including organ search (nationally only), harvesting and transportation. The benefit covers the cost of the donor if the recipient is an Imperialmed member

    Subject to Pre-authorisation (0860467374)
          Limited to R19 500 for organs from a cadaver
          or limited to R93 720 for live donor organ(s) per beneficiary per annum

    100%

    of Medical Scheme Rate

    e Anti-rejection drugs


    Subject to Pre-authorisation (0860467374)

    100%

    of Medicine
    Price

  • 13 HIV and AIDS
    All consultations, pathology and medicine related to diagnoses and treatment of the disease

    Subject to Pre-authorisation (0861 888 300) and clinical guidelines and protocols.

    HIV resistance tests provided only if pre-authorised by a relevant Case Manager on the YourLife Programme.
    Polymerase chain reaction funded from Major Medical Expenses for babies 18 months and younger where the diagnosis relates to HIV testing.

    Medicine subject to Mediscor Reference Price.

    Members are encouraged to make use of the Scheme's Preferred Provider Pharmacies.

    100%

    of Cost, unlimited

  • 14 Maternity Benefits
    a Normal delivery limited to three days - Labour and ward accommodation

    Additional days are subject to submission of a motivation by the attending doctor and approval by the Case Manager

    Subject to Pre-authorisation (0860467374)

    100%

    of Cost

          Elective caesarean delivery limited to four - days Labour and ward accommodation

    Additional days are subject to submission of a motivation by the attending doctor and approval by the Case Manager

    Subject to Pre-authorisation (0860467374)

    100%

    of Medical Scheme Rate (MSR)

    b Midwife

    Delivery by a midwife, confinement in a registered birthing unit or home delivery, including birth attendant and birth bath
    Midwife must be registered with the Board of Healthcare Funders and Nursing Council
    If a gynaecologist is not used, benefit covers pre- and post-confinement costs

    Subject to Pre-authorisation (0860467374). Four post-natal consultations with a midwife per event

    100%

    of Medical Scheme Rate

    cBenefits listed below are subject to enrolment on the Maternity Programme; if not registered on the Maternity Programme, benefits c1, c2, c3 and c4 are to be paid from day-to-day limits
    c1 Antenatal classes

    Only registered midwives

    BELLYBABIES ONLINE SUPPORT

    If you like the idea of enjoying your antenatal classes and consultations in the comfort of your own home, we invite you to make use of the unique Belly Babies online support programme, paid for by the Scheme from your available antenatal classes / antenatal consultations limits.

    By registering on www.bellybabies.co.za, you will be provided with expert antenatal and postnatal support in the comfort of your own home, through:

    • Access to an online antenatal course made up of a comprehensive collection of videos presented by experts within the maternity field;
    • An online consultation with a highly qualified lactation (breastfeeding) specialist to help you and your baby establish and maintain a happy breastfeeding routine; and
    • A follow-up online consultation with a lactation specialist, if needed.
    • If not registered on the maternity programme, this will be paid from the Day-to-Day Benefit Limits

    R1 120 per beneficiary per annum

    100%

    of Cost, as per authorised, registered Maternity Programme

    c2 Ultrasound scans (pregnancy)

    2 two-dimensional scans during pregnancy

    Two 2D or 3D or 4D scans per pregnancy up to 100% of the 2D scan at Medical Scheme Rate
    If not registered on the maternity programme, this will be paid from the Day-to-Day Benefit Limits

    100%

    of Cost, as per authorised, registered Maternity Programme

    c3 Antenatal vitamins during pregnancy

    R100 per month

    If not registered on the maternity programme, this will be paid from the Day-to-Day Benefit Limits

    100%

    of Medicine Price, as per authorized, registered Maternity Programme

    c4Gynaecologist consultations during pregnancy (as per care plan)


    100%

    at Cost, as per authorized, registered Maternity Programme

  • 15 Rehabilitation
    The benefit covers beneficiaries who are acutely disabled as a result of strokes, spinal cord injuries or brain injuries.
    The condition must be non-progressive.
    All associated accounts will be paid subject to this limit

    R74 000 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Medical Scheme Rate

  • 16 Psychiatric Institutions and Substance and Alcohol Abuse

    Maximum of 21 days per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Medical Scheme Rate

  • 17 Stoma Care Products

    Subject to Pre-authorisation (0860467374)

    100%

    of Medical Scheme Rate

  • 18 Cochlear Implants
    All requests are subject to approval by the Clinical Advisory Committee

    R250 000 per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    100%

    of Cost

  • 19 Dentistry
    a Dental alveolar surgery

    Surgical procedures involving the teeth and supporting jawbone ridges, such as:
    - Basic dental procedures in children under the age of eight
    - Surgical dental procedures in exceptional clinical scenarios in children older than eight and adults
    - Surgical removal of multiple/impacted teeth or roots
    - Apicectomies
    - Tooth exposures
    - Corticotomies
    - Surgical preparation of mouth for dentures, etc.
    - Wisdom teeth

    Subject to Pre-authorisation (0860467374)

    100%

    of Medical Scheme Rate for hospitalisation, operating theatre, sedationist and anaesthetist's fee

    Note that the associated dental procedures will still be funded at 85% of the Medical Scheme Rate from the respective Dental Benefit categories and sub-limits, as indicated under day-to-day benefits

    b Orthodontic related surgery

    Surgical procedures of:
    the jaw, facial bones, mouth and its various internal and surrounding structures, where required as part of an orthodontic treatment plan to improve the orthodontic malocclusion and related functional discrepancies; and/or to complement the nonsurgical portion of the orthodontic treatment plan

    R10 550 per beneficiary per annum, applies to surgeon's fee

    Subject to Pre-authorisation (0860467374)

    100% of Medical Scheme Rate for hospitalisation, operating theatre and anaesthetist's fee

    100%of Medical Scheme Rate for Surgical fee

    c Maxillofacial surgery

    - Oral/facial trauma, such as fractured jaw or facial bones for which hospitalisation is required
    - Oral cancer and similar aggressive oral pathologies
    - Cleft lip/palate repair
    - Salivary gland pathology
    - Serious life-threatening infection of dental origin
    - Internal temperomandibular joint (jaw-joint) pathology

    Subject to Pre-authorisation (0860467374)

    100%

    of Medical Scheme Rate for surgical procedures and related hospitalisation

  • 20 Excimer Laser, Radial Keratotomy, Holmium Procedures, LASIK, Phakic lenses and intra-stromal rings
    Surgically related services and procedures
    In line with Clinical Protocols

    R5 930 per beneficiary per annum
    Subject to Pre-authorisation (0860 467 374)

    100%

    of Medical Scheme Rate (MSR)

  • 21 Breast Reduction, Mammoplasty and other cosmetic surgery
    If deemed clinically appropriate

    Approval of Medical Advisor
          Subject to Pre-authorisation (0860467374)

    100%

    of Medical Scheme Rate

  • 22 Prosthetic Limbs and Eyes
    Prosthetic leg

    Subject to a limit of R69 050 per leg per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    The submission of a quotation prior to purchase is required
    Benefit is available every two to five years as per clinical protocols

    100%

    of Cost

    Prosthetic arm

    Subject to a limit of R69 050 per arm per beneficiary per annum
          Subject to Pre-authorisation (0860467374)

    The submission of a quotation prior to purchase is required
    Benefit is available every two to five years as per clinical protocols

    100%

    of Cost

    Prosthetic eye

    Subject to a limit of R21 300 per eye per beneficiary
          Subject to Pre-authorisation (0860467374)

    The submission of a quotation prior to purchase is required
    Benefit is available every two to five years as per clinical protocols

    100%

    of Cost

  • 23 Infertility
    Benefit limited to the treatment guidelines applied by State hospitals

    Limited to PMBs only
    Subject to Pre-authorisation (0860467374)

    100%

    of Cost

  • 24 Oncology
    a Treatment

    Subject to a treatment plan and enrolment on the Oncology Programme

    Overall Oncology limit of R291 040 per beneficiary per annum
    Subject to Pre-authorisation (0860467374)

    100%

    of Medical Scheme Rate
    if non-PMB;

    100%

    of cost if PMB

    b Brachytherapy materials

    Including seeds and disposables and equipment

    Limited to R35 990 per beneficiary per annum and included in the Overall Oncology limit
    Subject to Pre-authorisation (0860467374)

    100%

    of Medical Scheme Rate
    if non-PMB;

    100%

    of cost if PMB

    c Pathology, X-rays, MRI, CT and radio-isotope scans

    Limit of R31 590 per beneficiary per annum
    Subject to Pre-authorisation (0860467374)
    Not subject to the Overall Oncology limit

    100%

    of Medical Scheme Rate
    if non-PMB;

    100%

    of cost if PMB

    d Oncology medicine

    Subject to R291 040 Overall Oncology limit
         Subject to Pre-authorisation (0860467374)

    100%

    of Mediscor Reference Pricing (MRP)

  • 25 Services Rendered Abroad by a foreign supplier

    No benefit for beneficiaries travelling outside the borders of the Republic of South Africa for more than 90 consecutive days

    R1 000 000 per beneficiary per annum

    Paid in accordance with applicable benefits in the Scheme Rules and at Medical Scheme Rate
  • 26 Home Oxygen cylinders, concentrators and ventilation expenses

    R16 000 per beneficiary per annum
        Subject to Pre-authorisation (0860467374)

    100%

    of Medical Scheme Rate
    if non-PMB;

    100%

    of cost if PMB

  • 27 External Medical Appliances
    Permanent or temporary devices that are not surgically implanted

    Seen to improve the function of a diseased organ, e.g. wheelchair, crutches, CPAP machine, Baumanometer and all orthopaedic braces. Incontinence diapers, which are required as part of a chronic condition, are included

    R11 610 per beneficiary per annum
          Motivation required for devices and appliances above R1 000
          Subject to Pre-authorisation (0860 467 374)

    100%

    of Cost

  • 28 Hearing Aids

    R16 850 per beneficiary per year over a three year cycle
    Subject to an audiology report and pre-authorisation (0860 467 374)
    The three-year cycle is determined on the last claim date

    100%

    of Cost

  • 29 Prescribed Medicines
    Chronic medicine

    Prescribed for chronic conditions
    According to chronic medicine formulary only
    25% co-payment applies when using a non-formulary medicine

          Subject to Pre-authorisation (0860 467 374)
    The Scheme's dispensing fee is set at 26% for medicine below R100 and R26 for medicine above R100, or as agreed to by the Trustees from time to time at a non-network pharmacy or in accordance with the agreed fee at preferred provider pharmacies

    100%

    of Mediscor Reference Price (MRP)