The Scheme aims to give you and your family extra support in a time of crisis. Here we tell you more about the kind of help available to you.
Trauma Recovery Extender Benefit
The Trauma Recovery Extender Benefit provides members on both the Classic Comprehensive and Classic Saver plans with additional day-to-day cover following a specified list of traumatic events. The cover applies for the rest of the year in which the trauma takes place, and for the year after your trauma event.
How do I qualify?
You will have automatic access to this benefit if you meet the benefit entry criteria (refer to the image below). The benefit activates after you have been admitted for one of the specific traumas and the event has been appropriately reviewed and your benefits approved.
You must be a member of the Tsogo Sun Group Medical Scheme at the time that the trauma happens to qualify for cover from the Trauma Recovery Extender Benefit. The benefit covers only the claims for the member who is registered for the benefit and claims that are related to the original diagnosis after the specific trauma.
How does the Trauma Recovery Extender Benefit work?
The Trauma Recovery Extender Benefits covers you for certain day-to-day medical costs resulting from any of the following events:
Crime-related injury
The condition must require a high acuity admission i.e. High Care ward or Intensive Care Unit (ICU)
Severe burns
The condition must require a high acuity admission i.e. High Care ward or Intensive Care Unit (ICU)
Poisoning
The condition must require a high acuity admission i.e. High Care ward or Intensive Care Unit (ICU)
Severe anaphylactic (allergic) reaction
The condition must require a high acuity admission i.e. High Care ward or Intensive Care Unit (ICU)
Conditions related to a near-drowning
The condition must require a high acuity admission i.e. High Care ward or Intensive Care Unit (ICU)
Loss of limb due to direct blunt force trauma
Trauma-related loss of limb, for example due to direct blunt force trauma. The condition must require high acuity admission in a High Care ward or any amount of days in the Intensive Care Unit (ICU)
External and internal head injuries
The condition must require a high acuity admission i.e. High Care ward or Intensive Care Unit (ICU)
Paraplegia
Paralysis of the lower half of the body affecting both legs, due to blunt force injury to the spinal cord. Severe lessening of the strength or effectiveness of the limbs, shown by loss of reflexes, numbness and loss of motion in the spine. The condition must require a high acuity admission i.e. High Care ward or Intensive Care Unit (ICU)
Quadriplegia
Paralysis of both arms and legs due to blunt force injury to the spinal cord. Severe lessening of the strength or effectiveness of the limbs, shown by loss of reflexes, numbness and loss of motion in the spine. The condition must require a high acuity admission i.e. High Care ward or Intensive Care Unit (ICU)
How we pay
This benefit is subject to clinical entry criteria and covers expenses such as GP and specialist visits, private nursing, prescribed medicine, radiology and pathology.
These day-to-day medical expenses, which are normally paid from your Medical Savings Account, will be covered under this benefit. This does not pay for optometry, dentistry and over the counter medicines. Day to day limits that apply to claims paid from your day to day benefits also apply to the Trauma Recovery Extender Benefit. Please refer to the Member brochure for the limits that apply to your health plan.
Family members registered on the membership have access to 6 counselling sessions, starting from the day of the traumatic incident. These sessions will be available for the remainder of that year to the end of the following year.
Please refer to the Trauma Recovery Extender Benefit brochure for more information.
Caring for your mental health
Healthcare funders and providers worldwide have seen an increase in the number of people needing help with their mental health. Tsogo Sun Group Medical Scheme has carefully crafted benefits to help you and your family access the help you need.
Mental health disorders
We pay up to the agreed Scheme rate when you use a network facility. We cover a 21-day stay for an admission to treat major affective disorders, anorexia and bulimia, or up to 15 out-of-hospital consultations. You have cover for 12 out-of-hospital consultations for acute stress disorder accompanied by significant trauma.
The calculation of cover for these admissions can be complex when a mix of in and out of hospital care is needed, but we will let you know how many consultations you have when your doctors send through your benefit application.
Enhanced out-patient care
Members diagnosed with major depression or episodic depression have access to this programme, which lasts for six months but can be extended to 12 months when clinically appropriate. This benefit is activated when we receive a clinical motivation and a PHQ-9 assessment from your Premier Plus GP, who must then refer you to a psychologist in the Scheme's network.
Relapse prevention programme
Because we understand the importance of ensuring continued support after an initial admission for care, this benefit covers 2 psychiatric visits, 6 counselling sessions and care coordination services in addition to existing mental health benefits and Prescribed Minimum Benefits.
Alcohol and drug rehabilitation
You and your dependants each have access to 21 days of cover for treatment. The facility will contact the Scheme to arrange an admission, at which time we will send you confirmation of the admission approval, as well as the number of days available.
You are assured, then, that if you or your family faces a traumatic or stress-related mental health event, the Mental Health Benefit gives you the cover you need.
If you're unsure about the kind of benefits you have for trauma and mental health, give us a call on 0860 100 421 and we'll help you navigate your benefits.