BENEFIT DESCRIPTIONS

ACCIDENT


A sudden, unforeseen, unusual and unexpected specific event, which is unintended, arises from a source external to the Insured, is independent of illness, disease or other bodily malfunction, which occurs at an identifiable time and place during the period of the Policy.




ACCIDENT EMERGENCY SERVICE


All insured persons enjoy the benefit of road or air ambulance services when an ambulance service is needed with an accident event to and between medical facilities per year. EmergencyAmbulance means the response unit available to the Insured Persons

for urgent medical assistance by para-medics and ambulance services.




DOCTORS (General Practitioners / GP)


A doctor of medicine licensed to render medical services or perform surgery in accordance with the laws of the jurisdiction where such professional services are performed.




WAITING PERIOD


The Waiting Period is the period subsequent to the Participation Date, and stipulated in the Participation Certificate, in which no benefits to a Principal Insured or any of its Dependants or Extended Family Members will be paid




PAYMENT OF PREMIUM


  1. Premiums shall be payable monthly in advance by the third (3rd) day of the month in South African Rand.
  2. In the event of non-payment of the Premium on the due date, and subject to the provision of a 15 (fifteen) day grace period to pay the Premium in arrears, insurance cover in respect of the Insured Person shall lapse.
  3. It is the responsibility of the Insured Person to make sure premiums are paid on time.
  4. Premiums shall be payable by means of a debit order from a bank account nominated by the Principal Insured OR by manua deposits at the relevant partners All costs associated in respect thereof shall be borne by the Principal Insured.
  5. Children turning 21 years will, if not agreed otherwise, immediately become Adult Dependents and the increased amount as Adult Dependant shall be added automatically to the next month’s deduction.




EMERGENCY HOSPITALISATION


For an Accident resulting in Hospitalisation or any Trauma Unit, the compensation shall be limited to a maximum amount per Insured Person per year.




DENTAL - CROWN: when you need it


• A previously filled tooth where there now exists more filling than tooth.
• The existing tooth structure becomes weakened and can no longer
support the filling.
• Extensive damage by decay.
• Fractures.
• Root canal - After root canal, teeth tend to become brittle and are more




DENTAL - ROOT CANAL planneD & EMERGECY ROOT CANAL : when you need it


• Severe toothache while chewing food or severe pain while taking hot or cold liquid where examination shows presence of severe tooth decay.
• Darkening of the tooth or in case of an accident.
• A long standing dental infection in the bone that erodes through the side of the bone and causes sudden, serious and painful swelling.
• In case of severely worn out teeth, where a crown is being advised by the Dentist. Before placing a crown in such a case, that tooth may need Root Canal Treatment.




DENTAL- EXTRACTIONS PULLING OF TEETH


• Cavities reaching far under the gingiva or into the root.
• Severe loosening due to periodontitis.
• Lack of space or orthodontal lack of space.
• Longitudinal dental fractures.
• Root canal preparation in via falsa (root wall was drilled through
accidentally).
• Relocated or excess teeth.
• Severe tipping of teeth.




DENTAL - FILLINGS


• Tooth decay.
• Tooth fracture.
• After root canal treatment.
• Replacement of leaking restoration.




DENTAL - WISDOM TOOTH REMOVAL


Symptomatic bony impactions - are wisdom teeth which do not fully erupt into the mouth because of blockage from other teeth (impaction).




DENTAL - IMPLANT


• Where a permanent tooth (under insurance cover) is permanently decayed or deteriorated and no alternative procedure can save this tooth
(cover is supplied to replace such tooth with an implant).
• The Insured member cannot join and receive cover for a previously extracted tooth (The Administrator must have the extraction on record as paid, for cover to be granted for an implant).
• The extraction of the tooth must have been covered and approved or authorised by the Administrator in order to qualify for the replacement of this tooth via an implant.
• This benefit description is only applicable to the cost associated with the pin and the insertion thereof.
• The crown/cap required to complete the full procedure will be covered from the Crown benefits (if available). This will have to be authorized separately.
• An x-ray will have to be provided to prove that the pin has successfully been integrated before the crown/cap can be authorised.




X-RAYS


Black & White X-rays or scans required by the dentist or doctor




DENTAL - BITE PLATE


In dentistry, a plate made of some suitable plastic material into which the patient bites to cover the teeth to protect them from the strong vertical forces caused by grinding, which causes teeth to crack, break, and, over decades, slowly wear the teeth away to stubs.




DENTAL - MOUTH GUARD


A protective device for the mouth that covers the teeth and gums to prevent and reduce injury to the teeth, arches, lips and gums.




DENTAL - SCALE AND POLIS


A quick cleaning of the teeth carried out by a dentist. Usually using something called an Ultrasonic, the dentist will clean around the gum line on the back and front of your teeth to remove any plaque and tartar.




DENTAL - PAN SCAN


• This is a full mouth X-ray that will only be covered when joining the ShemDent Superior,MYCombo Superior and MyFamily SUperior options. • The cover is limited to Medicross or other facilities that has a panoramic radiograph machine. A benefit of R350 per nominated beneficiary is available and it is compulsory to submit this X-ray to DRUM for capturing and releasing of future benefits.
• Should you not use a MediCross facility for this scan, please be aware that other providers may also charge a consultation fee – please wait for your 3 month basic dentistry waiting period to be over so as to ensure that the Consultation benefit can be accessed.
• Should Specialised Dentistry pre-authorisation requests be submitted prior to the panoramic radiograph received, these will not be processed.




DENTAL - TRAUMA


• A trauma means an unforeseen and unplanned event or circumstance resulting in the injury of the jaw or teeth.
• Immediate medical treatment at any hospital’s ER unit must be needed due to the accidental injury.
• A hospital report will be required to moderate the treatment of the injury




DENTAL - PRE AUTHORSATION: when do you need it


• Wisdom teeth in chair or hospital
• Crown & Bridge work
• Implant
• Root canal treatment
• Temporary crowns
• Dentures




DENTAL - TEMPORARY CROWN


When in the process of placing a permanant crown





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© 2019 by ShemMed and ShemDent. 

NOTE WELL: this is not a medical aid and is not intended to replace any current medical aid plans you may already have.

This is an insurance product that can be used as EXTRA cover for your 

medical aid, hospital plan OR can be used on its own.