Exclusions

Like any other medical scheme, we are unable to cover certain procedures, products and services. These are listed as exclusions across all our plans and cannot be paid for from insured benefits. They may, however, be paid for from your day-to-day benefit (on HealthPact Select) or Medical Savings Account (on HealthPact Silver and Select), if funds are available.

The following exclusions apply across all plans:

• Ptosis repairs, blepharoplasties, or any procedure to correct eye refraction errors including, but not limited to, an excimer laser
• Treatment for sexual dysfunction and infertility, including in-vitro fertilisation
• Treatment for injuries sustained during professional sporting activities
• Treatment for injury or illness for which any other party is liable (unless CMP agrees to advance the benefits and is later refunded)
• Cosmetic procedures, including scar revision, Botox, breast reduction/reconstruction, and gynaecomastia
• Non-PMB treatment relating to alcohol or substance abuse, wilful self-injury or attempted suicide
• Non-PMB psychological and psychiatric treatment, including sleep studies
• Treatment and/or surgery for obesity
• Educational and group therapy
• Protective gear
• Non-PMB treatment for HIV/AIDS
• Treatment relating to or forming part of organ transplants, other than provided for in Rule 8.5 (HealthPact Premium), Rule 8.5 (HealthPact Silver) and Rule 8.5 (HealthPact Select)
• Drug-eluting stents
• External devices (including crutches, commodes, nebulisers, pronator boots, bed pans, raised toilet seats, wheelchairs, and CPAP machines)
• Hearing devices and cochlear implants (or the maintenance thereof)
• Artificial and synthetic blood products
• Dental implants, orthodontic treatment, prosthodontic treatment, orthognathic procedures, periodontic treatment
• General dentistry performed under general anaesthetic for minor beneficiaries
• Experimental or unproven treatments, procedures, devices and unregistered medicines, as per the Medicines Control Council 
• Household medicinal remedies, contraceptives, patent medicines, non-ethical and all proprietary preparations (including vitamins, supplements, minerals, medical creams, soaps, shampoos, and laxatives)
• Medical examinations for insurance, school, association, emigration, visa, employment or other applications
• Any treatments or costs not specifically provided for 

You’ll agree – our premiums are affordable and our cover extensive. It’s not easy to keep things that way, though. It takes careful planning on our part, and a couple of rules to keep us in check.

Some of these rules limit how we pay for certain products and services. We’ve done this on all procedures considered elective, like cosmetic surgery. We’ve also limited high-cost care to only medically appropriate, yet sufficient, cover.

We care for our members, and would love to pay for all claims, without exception. And without these limitations, that is exactly what we’d do. Unfortunately, we’d quickly become insolvent or be forced to increase our membership fees – even if we continued to stick to our over-arching philosophy of paying 99% of contributions back in benefits (the other 1% goes into our reserves).

By limiting expenses to only those deemed medically appropriate, you’ll always be covered for essential healthcare.