Hospital Plans

  • Hospital Plan Glossary

  • Accident means a sudden, uncertain and unexpected event which is caused solely and directly by violent, external, physical and visible means and independently of any other cause. Such accident must result in an external, visible injury confirmed by clinical examination and appropriate testing, and excludes the following:
    • Any events that is traceable to psychiatric trauma and the Insured Person’s state of mental or physical health prior to the event;
    • Non-visible soft tissue injuries excluding clinically confirmed ligament and tendon damage.

    Administration Fee refers to a percentage deduction from the Sum Assured which covers the claims administration costs. This percentage deduction may change from time-to-time.

    Beneficiary is the natural person nominated by the Policy Owner to receive the Life Cover Benefit in the event of death.

    Child means an unmarried dependant child, step-child, illegitimate child or adopted child (legally or by custom) of the Life Insured and includes a child who is over 21 and becomes dependant on the Life Insured by reason of mental or physical incapacity during the currency of the Policy.

    This definition further includes a grandchild being the child of any of the Life Insured’s children where both child’s parents are deceased or the child is a dependant of the Life Insured and satisfactory proof of dependency is submitted to the Insurer.

    A dependant child that has attained the age of 18 years or 21 years if a full time student shall no longer be covered under this policy. Proof will be requested at claim stage.

    Day means a period of 24 (twenty-four) consecutive hours of hospitalisation, including the day of admission but excluding the day of discharge.

    Hospital is defined as an institution which:
    • Is licensed in accordance with the applicable laws of the jurisdiction in which it is located;
    • Is primarily engaged in providing, for compensation from its patients, diagnostic, medical and surgical facilities for the care and treatment of injured or sick persons;
    • Has staff of one or more qualified Physicians available at all times;
    • Has 24 hour day nursing services by registered graduate nurses under the permanent supervision of the Physician in charge;
    • Maintains in-patient facilities;
    • Maintains a daily medical record for each of its patients;
    • Does not include any institution which is primarily a rest or convalescent facility, a place for custodial care, hospices, a facility for the aged or alcoholics or drug addicts or for the treatment of psychiatric or mental disorders, or a nursing home, even if it is registered as a Hospital or clinic.

    Illness means sickness or disease contracted and commencing during the currency of this Policy.

    Insured Person / Life Insured means the person(s) named as such in the Policy Schedule who is/are a resident(s) of the RSA (Republic of South Africa) residing in the RSA and in possession of a valid RSA identity document.

    Medical Specialist/Physician means a medical practitioner who, in addition to his/her basic medical degree, has specialised in a particular field and has graduated with an additional degree to that effect.

    Payment of Premiums and Commencement of Benefits The Benefits together with the relevant waiting periods commence upon receipt of the first Premium.
     
    Clientèle Life reserves the right to submit a debit instruction to your bank at any time during the month. Your authorisation allows Clientèle Life permission to apply any method of Premium Collection. In the event of non-payment of 3 (three) consecutive Premiums, the Policy will automatically lapse.

    Policy Owner shall be the person named as such in the Policy Schedule and is the initial payer of the Policy unless the Company is advised otherwise in writing.

    Pre-existing Medical Condition means Sickness or Bodily Injury sustained or contracted by an Insured Person for which he or she has or should reasonably have received relevant medical treatment or advice by a Physician, prior to such Insured Person’s initial Commencement Date or Reinstatement Date of Insurance under this Policy, whichever is more recent, including but is not limited to, any physical or mental defect, disease, infirmity or condition which existed prior to the initial Commencement or Reinstatement Date of this Policy whichever is more recent. Pre-Existing Medical Conditions will however be covered in full after the first 24 (twenty-four) Premiums have been paid from the Date of Commencement or Reinstatement Date, excluding the Accidental Disability Benefit.

    Spouse means the person married (whether by civil, customary, tribal or religious union) to the Life Insured and named in the Schedule. Cover is limited to one nominated spouse where a person has more than one.
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