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FAQ | Dis-Chem Health

Medical Insurance: Frequently Asked Questions

General

Can anyone join Dis-Chem 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.

What is a waiting period and how does it work?

No waiting periods apply to Accident Cover Policies.

 

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 1-month general waiting period on new policies where no claims will be covered. We will cover virtual GP consultations even when you are in a general waiting period, so you will be able to have a consultation with a doctor, if needed.

 

There is a 6-month waiting period for chronic medication if you have HIV and Diabetes Mellitus (type 2).

 

No general waiting period will apply to a newborn child or Eligible Spouse if you add them to your Policy within 90 days from the 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@kaelo.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 of 31 days before such a change.

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 is the difference between Medical Insurance and Medical Scheme (Aid) cover?

Medical scheme (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 Dis-Chem Health Primary Healthcare 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 Dis-Chem Health Accident Cover, which can be taken together with our Primary Healthcare 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 Dis-Chem 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 that of 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 Dis-Chem Health Primary Healthcare 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.

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

Policy Holder

Where can I get my membership card?

Dis-Chem Health Medical Insurance does not issue plastic membership cards. the Dis-Chem Health 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 Dis-Chem Health mobile app, go to Dis-Chem Health App. Register using your Policy Number and then select My Profile > Digital Card to view and download your membership card.

You can also use your Policy Schedule, which will be emailed to you when you take out a new Policy, to access benefits.

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 do I do if a benefit requires pre-authorisation?

To access the Benefit, you will require a pre-authorisation number. Log a query through the Dis-Chem Health App to request for authorisation. Alternatively, you can contact us on 0861 029 892 and one of our service consultants will assist you.

Do I need authorisation for maternity benefits?

Yes, you do need pre-authorisation to access the Maternity Benefit, which is subject to the Benefit limits on your chosen plan. Once you have selected your Network GP or Gynaecologist you or the provider should contact the call centre and request to speak to a Case Manager for pre-authorisation.

What is an exclusion?

An exclusion refers to the list of services and conditions which are always excluded from cover. Please refer to your relevant Policy Document: Policy Packs for more information about the exclusions on your chosen plan.

How is cover cancelled?

You may cancel your cover at any time, by giving 31 days prior written notice via email to dischemhealth@kaelo.co.za. The Insurer may cancel the Policy by giving 31 days’ notice for any reason. 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 to 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?

You can update your information in the Dis-Chem Health App, or contact the call centre on 0861 029 892 or email dischemhealth@kaelo.co.za. It is very important to keep your details up to date so we can effectively communicate with you, and to 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 the call centre on 0861 029 892 or email dischemhealth@kaelo.co.za

Am I covered for overseas travel?

No, international cover is not provided.

Medical Insurance Claims

Do I need to claim for Medical Insurance?

You shouldn’t need to claim for Medical Insurance. Provided you are using Network Providers, claims are paid on your behalf to the provider through your Policy. In most cases, you will need to present your membership card and ID to the contracted Network Provider and they will submit the claim directly to us for processing and payment. To avoid claims not being paid, first check that you have gone to a Network Provider as well as make sure you haven’t already exceeded any limits on your Policy for the year. When claims aren’t automatically paid to the Network Providers, such as:

  • Specialist visits
  • 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 and when can I claim for Medical Insurance?

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

IMPORTANT: The entire form must be completed for your refund to be processed. Your refund will be processed within 14 days of receipt of all the required information. Where no proof of banking details have been supplied, Prime Cure will not be held responsible for any payment made to the incorrect account.

If the claim is sent to you electronically, you can email the claim to dischemhealth@kaelo.co.za 

If your provider sends you a paper claim, you can post the claim to:

Private Bag 2108

Houghton

2041

Claims that are older than 120 days require proof that the claim was previously sent to Prime Cure. Failure to provide proof will result in the claim being rejected as stale.

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

Send the following documentation to dischemhealth@kaelo.co.za along with the refund request form which can be downloaded PrimeCure Request a Refund

  • A copy of your ID
  • The account for which the request is being made including:
    • The date of service
    • Practice number
    • Tariff/ICD-10 codes
    • Amount claimed.
    • Your receipt as proof of payment
    • Any requests over R3 000 must be accompanied by proof of banking details (stamped statement or confirmation letter).

Your refund will be processed within 14 days of receipt of all the information. Where no proof of bank details have been supplied, we will not be held responsible for any payment made into an 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 Dis-Chem Health or the Insurer indicated in the Disclosure Notice attached to the Policy wording within 90 days of receipt of the benefit/rejection letter. Dis-Chem Health or the Insurer is obligated to provide the Policyholder with feedback within 45 days.

The Policyholder should first aim to resolve their dispute with Dis-Chem Health before contacting the Insurer. Submit your concerns in writing to the Dis-Chem Health Complaints Manager by emailing dischemhealthesc@kaelo.co.za where our Executive Office will assist you. Should you wish to speak to us, please contact us on 0861 029 892. Should you wish to submit your complaint to the Insurer, please submit this in writing to the Internal Complaints Department of Centriq, for attention of Centriq Complaints Department using complaints@centriq.co.za. If you are dissatisfied with the response from Dis-Chem Health 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.

Mobile App

How do I access the Mobile App?

You can download the Dis-Chem Health App  from the Google Play, Apple or Huawei App Store. The App is currently only for clients on Medical Insurance or Accident Cover and not for Gap Cover. Use your policy number as your user name.

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

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 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 locate a Prime Cure Network doctor?

In the App on the menu tab select “Find Doctor”. The Mobile App will take you to the Dis-Chem Health website (Find a doctor page) 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”. There you will be able to view your: Brochure, Policy, Disclosure and Renewal Notice.

Prime Cure Network

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.

To search for a provider start by clicking the Search Using My Current Location (button)) or Enter an address: Find a provider

How do I find a Prime Cure Network Provider - Doctor/Dentist /Optometrist etc?

To find a Network Provider:

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 on 0861 029 892 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)

What is my Doctor (GP) Benefit?

On the MyHealth Plus option the Doctor (GP) Benefit is unlimited, and on the MyHealth Core plan you have 4 Doctor visits. You are required to pre-authorise your Doctor visits from the fourth visit by calling the call centre for the MyHealth Plus plan, and from the 3rd Doctors visit for the MyHealth Core plan.​

Can I go to any Doctor (GP), Dentist or Optometrist?

You need to go to a Prime Cure Network 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 on 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. ​

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 (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 pre-authorisation, depending on your chosen plan. When you visit a GP:

  • 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.

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 plan, 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. ​

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 a virtual consultation with the Prime Cure 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) Virtual Clinic 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 029 892 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) 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 (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.

Can a dispensing provider issue a script?

A dispensing provider may issue a script if they recommend a 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 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 approved formulary: Prime Cure Medicine Management

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.

How do Virtual Clinic visits work?

In addition to Doctor (GP) visits, you have access to Virtual Consultations via Prime Cure Virtual Clinics 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. ​

 

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. ​

Pharmacy and Medicine

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. To find a network pharmacy near you, visit the Prime Cure website, or log in to the Dis-Chem Health App.​

How do I find an approved pharmacy clinic?

All Dis-Chem pharmacies are approved on the network. To find a network pharmacy near you, visit Find a Doctor / Provider, or log in to the Dis-Chem Health 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 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 Scripted 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 wording for detailed benefits on the Chronic Conditions covered under your specific plan.

What is the Chronic Medication 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 www.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 medication 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) Medication?

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.

Clinic Based Care

What is the Nurse Benefit?

The Clinic Benefit is for the Treatment of minor Illnesses such as coughs and colds at a Network Wellness Clinic at a contracted pharmacy. 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

 

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 network 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 to a nurse in a clinic. 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 Screening Benefit?

You may visit any Prime Cure Network pharmacy clinic twice a year for a health screening. ​

The health screening consists of the following tests: ​

  • Blood pressure​
  • BMI (Basal Metabolic Index)​
  • Finger prick cholesterol test​
  • Finger prick glucose (blood sugar) test​
  • HIV/Aids test including pre- and post-test counselling.​

 

The claim will be submitted by the clinic directly to Prime Cure for payment. You must contact the nearest Prime Cure Network pharmacy for an appointment, at least 72 hours’ notice is required.​

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. You do not need to pre-authorise a general consultation with a dentist or a preventative treatment for cleaning. ​

However, a Dental Pre-Authorisation Request Form must be completed by the provider and submitted to dental.preauthorization@primecure.co.za in the event that you need: ​

  • Four or more repairs to teeth​ including filling
  • Five or more extractions​

 

If the Benefit is approved, a letter of authorisation will be emailed to the attending dental practitioner or therapist within three working days of receipt of the form. Please refer to your policy document for a detailed breakdown of Basic Dentistry Benefits and associated authorisation requests. 

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 plan. On the MyHealth Plus plan, after hours Treatment is limited to one visit per Family per annum for pain and sepsis only. You may visit any Dentist, but you may be required to pay upfront and then claim back from the Network Provider. The Network Provider will refund the Policyholder at the Agreed Rate.

Optometry

What is my optometry benefit?

On the MyHealth Core and MyHealth Plus plans you can visit a contracted Prime Cure Network optometrist once every 24 months. Failure to visit a contracted 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. We will cover frames, outside of the Prime Cure selection, up to a maximum of R600. If the frame costs more than the limit of R600, you will need to pay the difference in cost. ​ We do not cover tinting or contact lenses​

Specialists

What is the Specialist benefit?

This Benefit is only available on the MyHealth Plus plan. You can visit a Specialist which includes all additional services related to the consultation, such as radiology, pathology, scans, medication etc. The Specialist Benefit will only apply if you have obtained Pre-authorisation for the visit. For Pre-authorisation, contact the call centre on 0861 665 665. Please refer to your policy document for a detailed breakdown of the Benefit limits and associated Authorisation needed.​

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 obtain an authorisation. You can also send a query via the Mobile App or website relating to Specialist authorisation. We cover Specialist claims at the Agreed Rate. The Specialist consult is paid at an Agreed Rate, should a specialist charge above the Agreed Rate, you will be liable for the balance. 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.​

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.​

How do I claim or 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.

X-rays and Blood Tests

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, black and white 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 black and white X-rays and 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 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/

Hospital, Emergency & Accident Cover

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.

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.

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.

Any Specialist or follow up visits for medical cases are not be 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 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.

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 Netcare 911 on 082 911 or 010 209 8364 or hit the emergency button in the Mobile App. 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 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 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. 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 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.​

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.

Lifestyle Benefits: Virtual Consultations for Family, Legal and Financial Counselling?

How do I access Virtual Consultations for Family, Legal and Financial Counselling?

If you have the MyHealth Plus; MyHealth Core; Accident Cover with Lifestyle Benefits (or the combined plans), you have access to Family, Legal and Financial Counselling, with unlimited telephonic, virtual or face-to-face appointments. 

 

With Dis-Chem Health Virtual Counselling, you will be able to see a Lifestyle Professional  via video conferencing technology, or over the phone.  In order to book Virtual Counselling, you will need a Computer or Smart Phone with video functionality as well as a working internet connection.

 

To book, go to Virtual Counselling

 

Lifestyle Benefits are included in our Medical Insurance plans. You can also add them to Gap or Accident Cover plans, at R55 per month.

 

You also get access to extra by Dis-Chem: A 20% discount on over 2,500 products when you shop at Dis-Chem or Dis-Chem online.

 

For more information on Lifestyle Benefits, click here.

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