Major Medical Expenses - Health Plan

All Major Medical Expenses are subject to pre-authorisation. Please call 0860 467 374.

PRO RATA BENFITS

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 adjusted on a pro rata basis should a member join during the year.

Ex gratia and additional benefits
info As an employer-based restricted medical scheme, Imperial Motus Med 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, Imperial Motus Med will make a distinction between ex gratia payments and additional benefits.

info Ex gratia payments and additional benefits

  • Ex Gratia Payments

    Ex gratia payments will only be granted in cases where the Employer agree to pay 60% of the agreed ex gratia payment, while the Scheme will pay 40% of the agreed ex gratia payment. The following principles will be followed:

    • Day-to-Day benefits where the annual limit is not sufficient, could qualify for ex gratia payments;
    • Any other benefits where the opinion received from the Scheme's Managed Care Provider indicate that the care or level of care is not clinically appropriate from a cost efficiency point of view, taking into account clinical outcomes and cost; and
    • The determination of the value of ex gratia payments will always be calculated at Scheme Rate.
  • Additional Benefits

    Additional benefits will be funded by the Scheme and no Employer involvement or contribution will be required, but additional benefits will only be granted where a Clinical Opinion from the Scheme's Managed Care Provider indicate that the care or level of care is clinically appropriate from a cost efficiency point of view, taking into account clinical outcomes and cost. The following principles will be followed:

    • Major Medical benefits where there is a shortfall, could qualify for additional benefits;
    • Additional benefits will always be paid at Scheme Rate.
Imperial Motus Med Health Plan
Imperial Motus Med Budget Plan

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

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
    b Theatre fees

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
    c Medicines used in hospital/theatre

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medicine Price
    d A deductible of R1 000 applies if the following procedures are done in hospital:
    - 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 Expenses)
    - Nail surgeries
    - Minor skin lesions
    - Vasectomies
    - Conservative neck and back procedures
    - Circumcisions
    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 from day-to-day dental benefit
    e Circumcision

    Deductible applies, see 1a) above

    info R2 420 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
    fDental Procedures

    info 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%
  • 2Post-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.

    info 6 weeks' treatment, as per clinical protocols
          Subject to pre-authorisation (0860 467 674)

    100%
    of Medical Scheme Rate
  • 3GPs and Specialists in hospital
    a Visits and consultations

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
    b Surgical procedures and anaesthetics

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
  • 4Diagnostic Services
    a Radiology (X-rays) and pathology (in hospital)
    100%
    of Medical Scheme Rate
    b MRI, CT and radio-isotope scans (in and out of hospital)

    info R20 320 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
    c Ultrasound scans (in and out of hospital)

    info R5 450 per beneficiary per annum

    100%
    of Medical Scheme Rate
    d PET scans (in and out of hospital)

    info R28 000 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
    e Sleep studies, diagnostic polysomnograms (in and out of hospital)

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
  • 5To-take-out (TTO) Medicine

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

    info Subject to R520 per beneficiary per admission

    100%
    of Medicine Price
  • 6Out-patient Services
    Private and provincial hospitals
      • If the ICD-10 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 ICD-10 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
    85%
    of Scheme Rate for non-emergency

    info Emergency Medical Condition

    • An emergency medical condition means the sudden onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.

  • 7Blood Transfusions

    info In hospital
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
  • 8Nursing Services, Sub-acute Care and Hospice Services
    infoIncluding medicines, dressings, ointments, etc

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate or Cost, whichever is the lesser
  • 9Ambulance Services

    info R10 300 per beneficiary per annum
          Subject to approval and pre-authorisation by preferred provider, Europ Assistance (0861 737 283)
          Emergency air ambulance not subject to the above limit, subject to Scheme approval

    100%
    of Cost
  • 10Internal Prostheses
    infoIncluding all accompanying temporary or permanent devices used to assist with the guidance, alignment or delivery of these internal prostheses and devices
    infoPatients may obtain pre-authorisation 10 (ten) working days prior to admission for a joint replacement or spinal fusion operation
    Cardiac stents (including carrier)

    info Subject to a limit of R31 870 per stent (maximum of three) per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Cardiac stents - drug eluting

    info Subject to a limit of R32 790 per stent (maximum of three) per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Cardiac pacemakers

    info Subject to a limit of R61 240 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Cardiac valves

    info Subject to a limit of R42 650 per valve (limited to two) per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Cardiac pacemakers with defibrillator

    info Subject to a limit of R111 490 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Cardiac pacemakers with defibrillator - biventricular dual chamber

    info Subject to a limit of R221 550 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Aortic stents

    info Subject to a limit of R105 940 per stent (including the delivery system), limited to one stent per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Carotid stents

    info Limited to R18 530 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Detachable platinum coils

    info Limited to R41 800 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Embolic protection devices

    info Limited to R41 680 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Peripheral arterial stent grafts

    info Limited to R38 200 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    EVAR (Endovascular repair)/Anaconda

    info Subject to a limit of R189 900 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Hernia Mesh / Hernia Mesh Umbilical (Combined)

    info Subject to a limit of R13 040 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Total hip replacement

    info Subject to a limit of R58 190 per hip, including cement and antibiotics, per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Total knee replacement

    info Subject to a limit of R57 200 per knee, including cement and antibiotics, per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Total shoulder replacement

    info Subject to a limit of R51 810 per shoulder, including cement and antibiotics, per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Spinal instrumentation

    info Subject to a limit of R44 010 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Other approved spinal implantable devices and intervertebral discs

    info Limited to R48 530 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Bone lengthening devices

    info Limited to R39 400 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Neuro-stimulation/Ablation devices for Parkinson's disease and Vagal Stimulator for intractable epilepsy

    info Limited to R177 240 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Intraocular lenses

    info Limited to R9 330 per lens per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
    Any other internal prostheses

    info Subject to a limit of R49 740 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to sub-limits
  • 11Renal Dialysis
    infoInclusive of all related costs

    Benefit is subject to the submission of a treatment plan by the treating Specialist to the specialist care coach and approval of the treatment plan before treatment starts

    info Subject to pre-authorisation (0860 467 374)

    100%
    of the Negotiated Rate
  • 12Organ Transplants
    a Hospital accommodation and surgically related services and procedures

    info Subject to Pre-authorisation (0860 467 374)
          PMBs covered in full, i.e. heart, kidneys and liver
          Non-PMBs covered at Medical Scheme Rate, i.e. other organs

    100%
    of the Negotiated Rate
    b Heart, kidneys and liver

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

    info Subject to pre-authorisation (0860 467 374)
          Unlimited
          

    100%
    of Cost
    c Corneal transplant

    Including organ search (nationally only)

    info Subject to pre-authorisation (0860 467 374)
          R36 930 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 Imperial Motus Med member

    info Subject to pre-authorisation (0860 467 374)
          Limited to R36 930 for organs from a cadaver
          or limited to R117 200 for live donor organ(s) per beneficiary per annum

    100%
    of Medical Scheme Rate
    e Anti-rejection drugs

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medicine Price
  • 13HIV 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 specialist care coach 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
  • 14Maternity Benefits
    a Labour and ward accommodation

    Normal delivery limited to three days
    Additional days are subject to submission of a motivation by the attending doctor and approval by the specialist care coach

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Cost

    Elective caesarean delivery limited to four days
    Additional days are subject to submission of a motivation by the attending doctor and approval by the specialist care coach

    info Subject to pre-authorisation (0860 467 374)

    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

    info Subject to pre-authorisation (0860 467 374)
          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 post-natal 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 limits

    info R1 330 per beneficiary per annum

    100%
    of Cost, subject to pre-authorisation and registration on the Maternity Programme
    c2 Ultrasound 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 limits

    100%
    of Cost, subject to pre-authorisation and registration on the Maternity Programme
    c3 Antenatal vitamins during pregnancy

    infoR150 per month

    If not registered on the maternity programme, this will be paid from the day-to-day limits

    100%
    of Cost, subject to pre-authorisation and registration on the Maternity Programme
    c4Gynaecologist consultations during pregnancy (as per treatment plan)
    100%
    of Cost, subject to pre-authorisation and registration on the Maternity Programme
  • 15Rehabilitation
    infoThe benefit covers beneficiaries who are acutely disabled as a result of strokes, spinal cord injuries or brain injuries.
    infoThe condition must be non-progressive.
    infoAll associated accounts will be paid subject to this limit.

    infoR87 300 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
  • 16Psychiatric Institutions and Substance and Alcohol Abuse

    infoMaximum of 21 days per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
  • 17Stoma Care Products

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
  • 18Cochlear Implants
    infoAll requests are subject to approval by the Clinical Advisory Committee

    infoR294 940 per implant per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
  • 19Dentistry
    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

    infoSubject to pre-authorisation (0860 467 374)

    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 non-surgical portion of the orthodontic treatment plan

    infoR11 860 per beneficiary per annum, applies to surgeon's fee

    infoSubject to pre-authorisation (0860 467 374)

    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

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate for surgical procedures and related hospitalisation
  • 20Excimer Laser, Radial Keratotomy, Holmium Procedures, LASIK, Phakic lenses and intra-stromal rings
    infoSurgically related services and procedures
    infoIn line with clinical protocols

    infoR6 990 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
  • 21Breast Reduction, Mammoplasty and other cosmetic surgery
    infoIf deemed clinically appropriate

    info Approval of Medical Advisor
          Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
  • 22Prosthetic Limbs and Eyes
    Prosthetic leg

    infoSubject to a limit of R126 600 per leg per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    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

    infoSubject to a limit of R81 460 per arm per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    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

    infoSubject to a limit of R25 130 per eye per beneficiary
          Subject to pre-authorisation (0860 467 374)

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

    Limited to PMBs only
    infoSubject to pre-authorisation (0860 467 374)

    100%
    of Cost
  • 24Oncology
    a Treatment

    Subject to a treatment plan and enrolment on the Oncology Programme

    infoOverall Oncology limit of R369 250 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
    if non-PMB;
    100%
    of Cost if PMB
    b Brachytherapy materials

    Including seeds and disposables and equipment

    infoLimited to R47 640 per beneficiary per annum and included in the Overall Oncology limit
          Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
    if non-PMB;
    100%
    of Cost if PMB
    c Pathology, X-rays, MRI, CT and radio-isotope scans

    infoLimit of R38 870 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)
          Not subject to the Overall Oncology limit

    100%
    of Medical Scheme Rate
    if non-PMB;
    100%
    of Cost if PMB
    d Oncology medicine

    infoSubject to R369 250 Overall Oncology limit
          Subject to pre-authorisation (0860 467 374)

    100%
    of Mediscor Reference Pricing
  • 25Services 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

    infoR1 000 000 per beneficiary per annum

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

    infoR17 980 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
    if non-PMB;
    100%
    of Cost if PMB
  • 27External 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

    infoR13 690 per beneficiary per annum
          Motivation required for devices and appliances above R1000
          (Two-year cycle applies to Blood Pressure Monitors, Glucometers, and Nebulisers only)
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
  • 28Hearing Aids

    infoR20 070 for a unilateral hearing aid and R40 130 for bilateral hearing aid, 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
  • 29Prescribed Medicines
    Chronic medicine

    Prescribed for PMB and/or additional chronic conditions
    Subject to the chronic medicine formulary only
    10% Co-payment applies when using a non-formulary medicine

    infoR26 170 per beneficiary per annum
          Once limit is depleted, authorised PMB medication will still be paid
          Subject to pre-authorisation (0860 467 374)

    You have to register your chronic medication with the Scheme by either completing the chronic medication application form or your treating doctor can contact the Chronic Medicine Management Team.

    100%
    of Mediscor Reference Price (MRP)