Benefits
Optimal 2025 | Optimal 2026 | ||
Monthly premium: R510 per family for under 65yrs Monthly premium: R736 per family for 65yrs+ |
Monthly premium: R558 per family for under 65yrs Monthly premium: R806 per family for 65yrs+ |
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In-hospital benefits | Medical Expense Shortfall Cover | Increases the Medical Aid rate up to 500%. Subject to OAL | Increases the Medical Aid rate up to 500%. Subject to OAL |
Co-payment Cover | Subject to OAL | Subject to OAL | |
Non-DSP Hospital Penalty Cover | R13500 per admission. Limited to 1 claim per family per annum. Subject to OAL | R14700 per admission. Limited to 1 claim per family per annum. Subject to OAL | |
Sub-limit Cover | R33000 per insured. Limited to R72 000 per family per annum. Subject to OAL | R36000 per insured. Limited to R75 000 per family per annum. Subject to OAL | |
In-hospital and out-of hospital benefits | Traditional Cancer Cover | Co-payment cover for traditional cancer treatment limited to 20% per admission. Subject to the OAL | Co-payment cover for traditional cancer treatment limited to 20% per admission. Subject to the OAL |
Biological Cancer Drug Cover | Provides cover for Biological Cancer Drugs when the Medical Scheme imposes a sub-limit. Subject to a formulary and the OAL | Provides cover for Biological Cancer Drugs when the Medical Scheme imposes a sub-limit. Subject to a formulary and the OAL | |
Innovative Cancer Drug Cover | Provides cover for innovative cancer drugs. Limited to R12000 per claim. Subject to the OAL | Provides cover for innovative cancer drugs. Limited to R13000 per claim. Subject to the OAL | |
Breast Cancer Prevention Cover | Increases the Medical Aid rate up to 500% for a Prophylactic Mastectomy. Subject to OAL (Clinical Entry Criteria applies) | Increases the Medical Aid rate up to 500% for a Prophylactic Mastectomy. Subject to OAL (Clinical Entry Criteria applies) | |
Breast Cancer Reconstruction Cover | Increases the medical aid rate up to 500% for a breast reconstruction post mastectomy due to Cancer for the affected breast. Reconstruction of the unaffected breast for the purposes of symmetry, where there is no benefit on the Insured person’s Medical Scheme is limited to R22000 per insured person, per lifetime Subject to OAL | Increases the medical aid rate up to 500% for a breast reconstruction post mastectomy due to Cancer for the affected breast. Reconstruction of the unaffected breast for the purposes of symmetry, where there is no benefit on the Insured person’s Medical Scheme is limited to R24000 per insured person, per lifetime Subject to OAL | |
MRI and CT scan Cover | Provides cover for MRI and CT scans when there is no benefit available on your Medical Scheme. Limited to R7000 per event and 2 claims per family per annum. Subject to OAL | Provides cover for MRI and CT scans when there is no benefit available on your Medical Scheme. Limited to R7500 per event and 2 claims per family per annum. Subject to OAL | |
Trauma Care Cover | Covers the cost of trauma counselling consultations with a registered healthcare provider after a member has been diagnosed with a critical illness, a victim of a violent crime or experienced the death of an immediate family member. Limited to R3000 per consultation and R7000 per family per annum. Subject to OAL | Covers the cost of trauma counselling consultations with a registered healthcare provider after a member has been diagnosed with a critical illness, a victim of a violent crime or experienced the death of an immediate family member. Limited to R3300 per consultation and R7500 per family per annum. Subject to OAL | |
Out-of-hospital benefits | Co-payments for MRI, CT and PET scans | Subject to OAL | Subject to OAL |
Co-payments for Scopes | R6000 per event. Limited to 2 claims per insured per annum. Subject to OAL. | R6500 per event. Limited to 2 claims per insured per annum. Subject to OAL. | |
Sub-limit Cover for MRI, CT and PET scans | R33000 per event per insured. Subject to the OAL. | R36 000 per event per insured. Limited to R75000 per family per annum. Subject to the OAL | |
Casualty Benefit for Accidents | R12000 per event per insured. Subject to OAL | R13 000 per event per insured. Subject to OAL | |
Casualty Benefit for Illness | R5000 per event. Limited to 2 claims per family per annum. Subject to OAL. Treatment is restricted to between the hours of 6pm – 6am Mondays to Fridays, Saturdays, Sundays and Public Holidays | R5500 per event. Limited to 2 claims per family per annum. Subject to OAL. Treatment is restricted to between the hours of 6pm – 6am Mondays to Fridays, Saturdays, Sundays and Public Holidays | |
Added benefits | Medical Scheme Contribution Waiver | Up to R7500 per month for 6 months; in the event of death or permanent and total disability as a result of an accident, of the Medical Scheme Contribution Payer | Up to R8200 per month for 6 months; in the event of death or permanent and total disability as a result of an accident, of the Medical Scheme Contribution Payer |
Gap Premium Waiver | Pays the premium for your policy for 12 months in the event of death or permanent and total disability as a result of an accident, of the Contribution Payer | Pays the premium for your policy for 12 months in the event of death or permanent and total disability as a result of an accident, of the Contribution Payer | |
Personal Accident Benefit | R19500 per insured on the policy in the event of accidental death and permanent and total disability | R21000 per insured on the policy in the event of accidental death and permanent and total disability | |
Critical Illness Benefit | R9500 per insured on the policy in the event of death due to a critical illness (excludes cancer) | R10500 per insured on the policy in the event of death due to a critical illness (excludes cancer) | |
International Travel Cover | R5 million per insured (notification of travel required 48 hrs prior to departure) | R5 million per insured (notification of travel required 48 hrs prior to departure) | |
In-Hospital Dental Cover | Medical Expense Shortfall Cover | Increase the medical aid rate up to 500% for impacted wisdom teeth, reconstructive maxillofacial surgery due to an accident (which occurred while on the Policy) and oral cancer (which was diagnosed while on the Policy). Subject to the OAL | Increase the medical aid rate up to 500% for impacted wisdom teeth, reconstructive maxillofacial surgery due to an accident (which occurred while on the Policy) and oral cancer (which was diagnosed while on the Policy). Subject to the OAL |
Basic Dental Medical Expense Shortfall Cover for Children | Increases the Medical Aid rate up to 500% for basic dentistry for children up to and including 12 years old. Limited to R4000 per family per annum. Subject to the OAL | Increases the Medical Aid rate up to 500% for basic dentistry for children up to and including 12 years old. Limited to R4400 per family per annum. Subject to the OAL | |
Co-payment Cover | Subject to OAL | Subject to OAL | |
Sub-limit and Co-payment Cover for dental implants | Covers the cost of dental implants for reconstructive maxillofacial surgery due to an accident (which occurred while on the Policy) and oral cancer (which was diagnosed while on the Policy). Limited to R24 000 per admission and 50000 per family per annum. Subject to the OAL | Covers the cost of dental implants for reconstructive maxillofacial surgery due to an accident (which occurred while on the Policy) and oral cancer (which was diagnosed while on the Policy). Limited to R26 000 per admission and 50000 per family per annum. Subject to the OAL | |
Sub-limit Cover | R24 000 per admission and R50000 per family for impacted wisdom teeth, orthognathic surgery, reconstructive maxillofacial surgery due to an accident (which occurred while on the Policy) and oral cancer (which was diagnosed while on the Policy). Subject to the OAL | R26 000 per admission and R50000 per family for impacted wisdom teeth, orthognathic surgery, reconstructive maxillofacial surgery due to an accident (which occurred while on the Policy) and oral cancer (which was diagnosed while on the Policy). Subject to the OAL |
Additional Information
Biological Cancer Drugs
Click the button below to view the lists of the Biological Cancer Drugs covered under Optimal.
Waiting Periods
Click the button to review the Waiting Periods and Exceptions
