12. Definitions and Abbreviations

12.1 Act

The Medical Schemes Act, 1998, as amended or replaced from time to time, and the regulations promulgated thereunder.

12.2 Acute medicine

Medicine used for diseases or conditions that have a rapid onset, severe symptoms, and that require a short course of medicine treatment, as well as medicines that qualify for benefits but have not been classified as chronic medicine by the Scheme.

12.3 Adult
A dependant who is 21 years or older, excluding full-time students on Selfmed 80% and Selfsure options who are younger than 25.

12.4 Agreed tariff (AT)
A tariff as agreed upon, and amended from time to time, by or on behalf of the Scheme and its preferred providers and/or for medicine: the single exit price (Medicines and Related substances Act No 101 of 1965) plus dispensing fee and/or MMAP, whichever is lesser.

12.6 Basic dentistry
Examinations; and/or X-rays; and/or plastic and soft-based dentures, limited to one set per jaw per annum; and/or simple corrections to all teeth; and/or preventative dentistry including scaling and polishing of teeth, fluoride treatment, sealing teeth to prevent tooth decay, oral hygiene education in respect of the brushing of teeth, as well as flossing techniques; and/or root canal therapy to front teeth, including premolars; and/or sedation; and/or local anaesthetics; and/or sterilised instrumentation; and/or occlusal guard.

12.7 Beneficiary
Each individual member and dependant.

12.8 Biologicals
a Substance that is made from a living organism or its products and includes vaccines therapeutic proteins (e.g. insulin) and monoclonal anti-bodies.

12.9 Case Management programme
A process whereby clinically indicated, appropriate and cost-effective healthcare, as an alternative to hospitalisation, or otherwise, is offered to individual beneficiaries with specific healthcare needs - whether the Scheme prescribes it, or approves it on application by a beneficiary

12.10 Chemotheraphy
Medication used in the cure and containment of cancer. This includes cytostatics and hormone inhibitors and excludes medication not directly related to the treatment of cancer (e.g. antidepressants) and medication used in the treatment of long-term conditions that may develope as a result of the cancer treatment.

12.11 Chronic medicine
Medicine that meets all the following requirements:

• prescribed by a medical practitioner for an uninterrupted period of at least three months; and
  
• for a condition appearing on the Scheme’s list of approved chronic conditions, as amended from time to time; and
  
• which has been applied for in the manner and at the frequency prescribed by the Scheme from time to time, and which application has been accepted by the Scheme.

12.12 Clinical procedure

A procedure categorised as such by the Scheme.

12.13 Dependant
The following persons for whom the member is liable for care and support, who are not members or dependants of members of any other medical scheme, and, if applicable, who are duly registered as dependants by the Scheme:

• a spouse; and/or partner (NOT an ex-spouse),
  
• a child - including an adopted child, stepchild or foster child; and/or
  
• the member’s parents (including adoptive parents), sisters and brothers; and/or
  
• any other person approved by the Scheme.

12.14 Disease management
A holistic approach focusing on the patient, using all the cost elements of the disease to identify the patient eligible for a disease management programme. The intervention takes place by means of:

• Patient counselling and education
  
• Behaviour modification
  
• The application of therapeutic guidelines
  
• Incentives and penalties; and
  
• Case management.

12.15 Effective date

The date on which a beneficiary becomes entitled to benefits.

12.16 Elective dental surgery

Dealing with the cause and treatment of malposition of the jaw-bones, and/or alveolar ridge augmentation.

12.17 Family

A member and his/her dependants.

12.18 Foreign claims

Claims originating from countries outside the borders of the Republic of South Africa.

12.19 Generic Reference Price
The maximum price payable for generic equivalents or therapeutic equivalents.

12.20 Hospital
Includes a mental health institution, registered unattached theatre and day clinic, but excludes an institution for rehabilitation for substance abuse.

12.21 Implantology
All stages of treatment required to achieve the end result of placing an implant supported tooth or teeth into places left by previous removal of natural teeth. This includes the surgical augmentation of the jaw bone, surgical placement and exposure of implant(s).

12.22 Inception date
The date on which a person becomes a member of the Scheme or on which a dependant’s registration becomes effective.

12.23 Late joiner
An applicant or the adult dependant of an applicant who, on the Application Date, is 35 years or older. This excludes any beneficiary who enjoyed cover with one or more medical schemes prior to 1 April 2001, and who did not have an interruption in cover of more than 90 days since 1 April 2001. A certificate of previous membership may be required.

12.24 Major Medical Benefits
Insured benefits for services such as hospitalisation and the treatment/procedures performed whilst a beneficiary is hospitalised.

12.25 Medical auxiliary services
A person or entity

• whose discipline is explicitly covered by the
  Scheme rules; or
  
• with a practice code beginning with 090 (issued by the Board of Healthcare Funders), whose type of service rendered has been approved (in writing) by the Scheme.

12.26 Medical Scheme Rate
The National Health Reference Price published by the Department of Health or such other tariff agreed by the Scheme.

12.27 Medicine
A substance registered under the Medicines and Related Substances Control Act, 1965, as amended or replaced from time to time.

12.28 Member
A person who has been registered as a member by the Scheme.

12.29 Minor
A dependant who is not yet 21 years old, and, under the Selfmed 80% and Selfsure Options, a dependant who is over the age of 21 but not over the age of 25 years, who is studying full time at a recognised institution.

12.30 Non-elective dental surgery
The treatment of cysts and tumours of the jaw, as well as conditions of the saliva glands; and/or the treatment of abscesses of the jaw (with the exception of periodontal therapy); and/or the treatment of all traumas to the bone and soft tissue of the face; and/or extractions or the surgical removal of teeth.

12.31 Orthopaedical appliances
External spinal and/or major joint appliances with the explicit function to provide stability afteroperative procedures, e.g. cervical and lumbar spine supports, knee and ankle braces and shoulder support.

12.34 Pre-authorisation reference number (PAR)
A number allocated by the Scheme’s managed healthcare agent, which is required before certain services qualify for benefits.

12.35 Preferred Provider
A Service Provider with whom preferential rates were negotiated by or on behalf of the Scheme, or who is part of a preferred provider network contracted for or on behalf of the Scheme.

12.36 Prescribed Minimum Benefits
The minimum benefits that the Scheme is obliged to provide under the Act.

12.37 Prosthesis
A device that replaces a missing or nonfunctioning body part or organ.

12.38 Registrar
The Registrar of Medical Schemes appointed under the Act.

12.39 Self-payment gap
A period during which a member will be required to fund a certain portion of day-to-day claims from his/her own pocket.

12.40 Service date In the event of:

• hospitalisation - the date of each discharge from a Hospital; or
  
• any other service or supplies - the date on which the service was rendered or the supplies obtained, whether for the same illness or not.

12.41 Service provider
A medical practitioner, dentist, pharmacist, nurse,clinical psychologist, medical auxiliary or hospital duly registered or licensed as such with a statutory council or relevant state department – or if practising in a territory outside South Africa, registered or licensed as such with a similar body in that territory.

12.42 Specialised dentistry
Metal frames for full or partial sets of dentures; and/or root canal therapy for molars; and/or resin, porcelain or metal inlays in teeth for which simple corrections are not adequate, with the exclusion of metal inlays in front teeth and dentures. Periodontal treatment; and/or crown and bridge work; and/or the bleaching of root-canal-treated teeth that have discoloured as a result of the removal of nerves; and/or orthodontic treatment; and/or components bonded to previously placed implants. All services, except for hospitalisation, qualify for dental benefits, if these are provided or rendered in respect of conditions related to dentistry.

12.43 Spouse
A person to whom a member is married under a system recognised by South African law.

12.44 Year
A period of 12 months beginning on 1 January and ending on 31 December.