Synergy 2020

Turnberry shall not be liable for hospitalisation, bodily injury, sickness or disease directly or indirectly caused by, related to or in consequence of:

1. 1. Nuclear weapons or nuclear material or by ionising radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel. For the purpose of this exception combustion shall include any self-sustaining process of nuclear fission;
   2. LASIK or Lasik (laser-assisted in situkeratomileusis) surgery or any type of refractive surgery for correcting myopia, hyperopia, and astigmatism;
   3. Investigations, treatment or surgery for obesity its sequela or cosmetic surgery or surgery directly or indirectly caused by or related to or in consequence of cosmetic surgery other than as a result of an insured event otherwise insured. For the purpose of this exception cosmetic surgery shall include surgery for breast reduction or reconstruction unless necessitated as a result of treatment for cancer;
   4. Routine physical or any procedure of a purely diagnostic nature or any other examination where there are no objective indications of impairment in normal healthand laboratory diagnostic or X-ray examinations except in the course of a disability established by prior call or attendance of a Medical practitioner;
   5. Suicide, attempted suicide or intentional self-injury;
   6. The taking of any drug or narcotic unless prescribed by and taken in accordance with the instructions of a Medical Practitioner (other than the Insured person) or drug addiction;
   7. An event directly attributable to the Insured person having an alcohol content exceeding the legal limit or the Insured person suffering from alcoholism or any illness caused by the use of alcohol;
   8. Participation in:
      a. Active military duty, police duty, police reservist duty, civil commotion, labour disturbances, riot, strike, or the activities of locked-out workers
      b. Aviation other than as a passenger
      c. Any form of race or speed test (other than on foot or involving any non-mechanically propelled vehicle, vessel, craft or aircraft);
   9. Investigations, treatment or surgery for artificial insemination or hormone treatment for infertility;
   10. No benefits are payable which should be provided by the Medical Scheme, this exception includes ward fees, theatre fees, medicines, appliances and other hospital expenses;
   11. No benefits shall be payable in the event of fraudulent submission by the claimant;
   12. No benefits shall be payable in the event the insured did not pre-authorise, make use of a Designated Service Provider (this is not applicable to the Non-DSP Hospital Penalty Cover on Premier, Optimal and Synergy) or any condition set by the Insured’s Medical Scheme;
   13. No benefits shall be payable in the event there is no benefit for the treatment and/or the condition or if it is excluded and/or declined by the Insured’s Medical Scheme (including split billing) or if the Medical Scheme pays less than tariff for benefits associated with costs incurred above Medical Aid rate;
   14. No benefit shall be payable in respect of any medical or surgical treatment unless such treatment occurred during the period of hospital confinement as an in-patient or as an out-patient (as defined);
   15. The table of benefits applies in the territory of the RSA and no benefits are payable for expenses incurred for transport charges or for services rendered whilst being transported in any emergency vehicle, vessel or aircraft;
   16. No ward fee benefits shall be payable in respect of any additional costs incurred as a result of confinement to a private ward if such confinement to a private ward was requested by the Insured person;
   17. Treatment resulting from failure to carry out the instructions of a Medical Practitioner;
   18. Treatment for the Casualty Illness Benefit when treatment was not received between the hours of 19:00-06:00 Mondays-Fridays, Saturdays, Sundays and Public Holidays;
   19. Injuries arising from professional sport or any other recreational activity which is not commonly recognised as a sport and/or involves uncontrolled competition, unusual skill or violent activity and is generally considered to be inherently dangerous for the emergency casualty benefit (as defined in the Policy document) provided in a hospital out-patient emergency facility;
       ADDITIONAL EXCEPTIONS APPLICABLE ONLY TO PREMIER, OPTIMAL AND SYNERGY OPTIONS
   20. Psychiatric conditions including but not limited to depression, insanity, mental and or stress related conditions for co-payments and sub-limits;
   21. Co-payments and Sub-limits are covered for dentistry except for investigations, treatment or surgery related to dental implants, except in the event for reconstructive maxillofacial surgery as a result of oral cancer or an accident (which occurred/ was diagnosed while on the Policy) and will be limited to R50 000 per policy per annum. No benefit is payable while an Insured person is within a waiting period;
   22. Benefit 1 (Private Rate Cover) for dentistry is limited to impacted wisdom teeth and/or reconstructive maxillofacial surgery as a result of an accident while on the Policy. No benefit is payable while an Insured person is within a waiting period;
       ADDITIONAL EXCEPTION APPLICABLE TO TRAUMA RECOVERY COVER
   23. The step down facility must be authorised and paid from the Medical Scheme’s Risk Benefit (i.e. not from day to day benefits);
       ADDITIONAL EXCEPTION APPLICABLE TO LAUNCH OPTION
   24. The first R350 per event will be the liability of the Principal Insured Person;
       ADDITIONAL EXCEPTION APPLICABLE TO MED-EXTEND OPTION
   25. For the Defined Procedures listed on the Policy no benefit shall be payable unless the Defined Procedure has been fully declined by the Insured person’s Medical Scheme.