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GapCover

Fusion™ TechnicalGuide 2017

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Contents1. Who We Are -------------------------------------------------------------------------------------- 1

2. Our Business Model --------------------------------------------------------------------------- 2

3. Fusion™ ------------------------------------------------------------------------------------- 2 - 5

4. Terms & Conditions ---------------------------------------------------------------------------- 6

5. Waiting Periods ---------------------------------------------------------------------------- 7 - 8

6. Exclusions ---------------------------------------------------------------------------------------- 8

7. Premiums - 2016 ------------------------------------------------------------------------------- 9

8. Quotations ------------------------------------------------------------------------------------- 10

9. Application Procedure ---------------------------------------------------------------------- 10

10. Claim Procedure ------------------------------------------------------------------------------ 11

11. Contact Details ------------------------------------------------------------------------------- 12

12. Waiting Period Overview ------------------------------------------------------------------ 13

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1. Who We Are KaeloXelus™ is registered with the Financial Services Board as an underwriting manager and all our products are fully underwritten by Centriq Insurance Company RF Ltd.

Centriq holds a credit rating of AA from Global Credit Ratings and is also a wholly-owned subsidiary of Santam, the largest short term insurance company in Africa.

Santam is also the only short term insurer in South Africa that carries the highest credit rating possible (AAA) from Global Credit Ratings.

These excellent financial ratings provide all KaeloXelus™ clients with total financial security and complete peace of mind. Listed below are some of the corporate clients who enjoy cover with KaeloXelus™.

Intermediary

ClientsIntermediaryContract

InsuranceAgreement

ClientAppointment

100%Owned

Binder Holder

Stakeholders in the KaeloXelus™ value chain

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2. Business ModelKaeloXelus™ has a unique business model that offers superior value to clients.

Our longstanding partnership with Centriq allows us to share underwriting risks, making us a partner in the management of claims risk.

This alignment of risk sharing allows KaeloXelus™ to deliver administration services and distribution support at substantially lower costs than the market average. These lower costs allow us to allocate a greater portion of client premiums to cover claims, enabling superior benefits at lower premiums for all Fusion™ clients.

The graph below illustrates how the KaeloXelus™ business model differs from the typical business structure of other providers.

Our total administration and support costs equal 13% of client premiums, which is substantially lower than the market norm of ±23%. This increases the net premium available in our risk pool by nearly 18%, enabling us to cover more claims and deliver superior value.

KaeloXelus™ manages all administrative aspects of Fusion™, including premium collection, new business applications, member queries and processing of claims.

Our products are distributed exclusively by independent intermediaries and we allocate a dedicated business development consultant to each brokerage.

3. Fusion™ BenefitsKaeloXelus™ offers the ideal, singular solution for optimal gap cover through Fusion™. Fusion™ integrates with members existing medical scheme, delivering comprehensive cover for all in-hospital and oncology-related shortfalls. For intermediaries, Fusion™ eliminates any FAIS liability regarding the advisory process, as there is no need for the member to make an option choice. Our singular approach is easy to communicate and simple to understand with comprehensive cover provided to members.

The following sections provide an explanation on each category of cover - please note that these benefits are effective as from 01 October 2016 for all policyholders:

The KaeloXelus™ Business Model provides 18%

more in the risk pool to cover

claims.

Market Norm

Administration & Support Costs

Commission

Premium Available to pay Claims

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In-Hospital Cover

The following in-patient shortfalls are covered:

Tariff Shortfalls - an additional 500% above medical scheme tariff. All services - including PMB - delivered while in-hospital are covered, such as surgeons, anaesthetists, physiotherapists, radiology, pathology, CT/MRI scans, etc, etc.

There is no limit on this benefit.

Co-payments & Deductibles – Any fixed value co-payment or deductible that is applied against scheme benefits is covered. This benefit is payable regardless of whether the co-payment or deductible was paid from a medical savings account.

This covers hospital admissions, defined surgical procedures, basic in-patient dentistry, CT/MRI/PET scans and endoscopes.

There is no limit on this benefit.

Penalty Co-payment/Deductible – Any penalty co-payment or deductible that is applied against the scheme benefits for the voluntary use of a hospital or day clinic that is not a designated service provider. This benefit is payable regardless of whether the co-payment or deductible was paid from a medical savings account.

This benefit is limited to 1 event per family per annum and is limited to a maximum of R12,000.

Sub Limit Enhancer – shortfalls arising from the application of an annual sub-limit for a specific medical category of service will be covered (eg prosthesis for joint replacement, MRI/CT scans, etc, etc). Cover does not apply where a scheme has not approved a benefit – only where a sub-limit, as registered in the medical scheme rules, applies to the cover.

This benefit is limited to a maximum of R40,000 per event or condition. No annual limit applies.

Out-of-Hospital Cover

The following out-patient shortfalls are covered:

Oncology

Oncology Tariff Shortfalls - Fusion™ provides an additional 500% of tariff on all oncology related services, such as oncologists, biological drugs, chemotherapy, radiotherapy, radiology, specialised scans, pathology etc.

There is no limit on this benefit.

Oncology Co-Payments - Co-payments that are applied by a medical scheme, once oncology costs reach a pre-

defined threshold, are covered up to a maximum of 20%, subject to a limit of R325,000 per beneficiary per treatment cycle. This means that if a member undergoes 2 treatment cycles in the same year, each treatment cycle will receive a benefit of up to R325,000.

There is no annual limit on this benefit.

This benefit applies to all related costs including biological drugs. No formulary of biological drug types is applied and all types of cancer are covered.

Oncology Sub-Limits - Where a medical scheme applies an overall sub limit to oncology benefits, Fusion™ will provide additional cover, once such limited scheme benefit is exhausted, up to a maximum of R220,000 per beneficiary per annum.

Cover does not apply where a scheme has not approved a benefit or does not have a benefit – only where a sub-limit, as registered in the medical scheme rules, applies to the cover.

This benefit applies to all oncology related treatment, including biological drugs in accordance with the following formulary: Alimta, Avastin, Erbitux, Faslodex, Fludara, Gleevec, Herceptin, Mabthera, Mylotarg, Nexavar, Sprycel, Sutent, Tarceva, Velcade & Zevalin

Tariff Shortfalls – Tariff shortfalls arising on the following out-patient treatment will also be covered up to an additional 500% of medical scheme tariff:

Endoscopes – Any form of endoscopic procedure performed out-of-hospital that would otherwise, if performed in-hospital, attract a co-payment or deductible from the medical scheme.

Dental extractions - Any form of surgical dental extraction performed out-of-hospital that would otherwise, if performed in-hospital, attract a co-payment or deductible from the medical scheme.

Dialysis – this relates to the fees of a haematologist.

Home birth – this relates to the fees for a medical practitioner, nurse or mid-wife for a non-hospital birth.

Accidental Casualty Cover – The cost of all treatment provided at an out-patient casualty ward for injuries resulting from accidental harm is covered. All related services are covered, eg specialists, medication, radiology, MRI/CT scans, etc. This benefit is payable regardless of whether the treatment costs are paid from a medical savings account.

This is subject to a limit of R12,000 per event or condition. No annual limit applies to this benefit.

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Benefit Extender

We understand that certain medical events result in additional non-medical expenses that will not be covered by your medical aid.

Our Benefit Extender was designed to assist you with additional benefits for exactly such events. These benefits are paid over and above the core benefits above and can be used entirely at your discretion

Dental Reconstruction

Benefit

Family Booster

Contribution Waiver

Family Protector

Hospital Booster

Road Accident Fund (RAF)

Dental Reconstruction Benefit

If a beneficiary requires dental reconstruction as a result of trauma or oncology treatment, we will cover such costs up to R36,000 per event. This benefit only applies to events occurring after commencement of cover.

Contribution Waiver

If the principal member of the medical scheme dies or becomes permanently disabled, Fusion™ will cover the medical scheme contributions for 6 months up to a maximum of R4,000 per month. The Fusion™ premium will also be waived entirely for 6 months.

Road Accident Fund (RAF)

If you are injured in a vehicle accident that wasn’t your fault, our partners – Road Cover – will provide you with all the legal assistance to finalise your claim. The entire award from the RAF will be paid out to you – we cover all the legal costs for free.

Family Booster

For a premature birth more than 6 weeks before due date, Fusion™ will pay you R12,000.

Family Protector

Should you or any beneficiary die or become permanently disabled, we will pay a lump sum of R12,000. If the cause was accidental, the benefit doubles to R24,000.

Hospital Booster

Fusion™ will pay a lump sum related to the length of stay in hospital, as follows:

From day 7 to 13 we will pay R600 per day

From day 14 to 20 we will pay R1,200 per day

From day 21 to 30 we will pay R1,800 per day

If the hospitalisation was trauma related or for a premature birth more than 6 weeks before due date, we will pay the benefit from day 1 instead of day 7.

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FusionXFusionX integrates the Fusion™ benefits with our EAP services at a reduced rate for corporate clients.

Modern lifestyles are busy, stressful and pressured, often leaving employees weary, emotionally burdened and needing support to help them cope. FusionX is the optimal integrated solution, combining the advantages of Fusion™ gap cover with the benefits of our proven Employee Assistance Programme (EAP).

Comprehensive Health and Wellness Solutions

Employees encounter personal challenges like managing relationships, conflict, parenting responsibilities, financial pressure, work-related stress, legal problems and mental health challenges like depression, anxiety and addictions. These factors all take their toll on people, impacting their concentration, their health, their productivity and their work performance. If employees are not assisted to manage their personal challenges, the impact in the workplace can be detrimental, with problems like illness, absenteeism, negligence and low productivity.

A Proven Solution in Times of Trouble

Our EAP services support employees to manage their difficulties and cope well with any personal difficulties they encounter. All our services are delivered through a dedicated team of skilled health professionals who support employees and their immediate family to manage emotional and life’s daily challenges. Our interventions are well-managed and effective in enhancing health and well-being. With FusionX, employees enjoy comprehensive health cover as well as confidential assistance for optimal well-being. The end-result is a healthier and happier workforce, with reduced absenteeism, higher productivity, strong morale and effective human capital.

Family Support for Dependants

Counselling:Telephonic

(24/7/365) & Face-to-face

FinancialSupport

Managerial Support

Marketingand Health Education

Online Health Portal

TraumaSupport

LegalSupport

24-HourHealth Line

Comprehensive EAP Services

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4. Terms and ConditionsThe following Terms & Conditions are applicable to Fusion™:

• Maximum entry age is 60 for individuals and groups less than 20. This maximum entry age increases to 65 for groups of 20 or more

• Waiting periods apply to cover - please check the issued member schedule or contact us to confirm

• Cover only applies to the member, spouse & children (up to 26)

• Families covered on 2 medical aids will be covered by a single Fusion™ policy

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5. Waiting Periods Only 2 types of waiting periods apply to Fusion™:

• Pre-existing waiting period of 12 months. Pre-existing is defined as any condition that exists at the time of application or for which advice, treatment or diagnosis was sought/made in the 12 months preceding the date of application for cover.

• Maternity waiting period of 12 months. Maternity waiting period applies to all related treatment and is regardless of whether the applicant was aware of the pregnancy or not at the time of application.

These waiting periods can be waived, depending upon the eligibility criteria of the group (i.e. voluntary or compulsory membership), as outlined below.

5.1 Compulsory Groups of 20+

If compulsory groups of 20 or more join KaeloXelus™, both waiting periods will be waived for the group. This waiver will also apply to new future members of this group after the group has commenced cover with KaeloXelus™.

5.2 Voluntary Groups of 20+

The following waiting period rules will apply to all future members of the group, as per the details below.

• Members who join within 2 months of commencing employment at the group,

OR

• Members who join during a window period provided by KaeloXelus™**

For members of voluntary groups meeting the above criteria, waiting periods are applied as follows:

If they answer ‘No’ to the single medical question in their application form, the Pre-existing waiting period will be waived.

The Maternity waiting period applies regardless of the answer on the medical questionnaire.

If existing voluntary groups of 20 or more transfer cover from another gap provider to KaeloXelus™, the waiting periods for the transferred members will be waived. All existing gap cover members are required to transfer as a group, unless otherwise agreed upon in writing with KaeloXelus™.

See Section 12 for a quick overview of how waiting periods are applied to voluntary groups of 20+ members.

** - Members of voluntary groups of 20+ who do not meet one of these two criteria, will be treated as per Section 5.3 below.

5.3 Any Group under 20 (incl private individuals)

For any group of less than 20 (voluntary or compulsory) or for private individuals, both waiting periods will apply to cover, regardless of the answer to the medical question on the application form.

Medical underwriting can also occur - this indicates that we will assess the health status of the applicant and may impose permanent exclusions on certain conditions (applicants will be asked to sign acceptance of such cover) or possibly decline the application.

The medical questionnaire completed on the application form will be taken into account for Medical Underwriting purposes or we may ask the applicant for further information.

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5.4 Important Notes

• Waiting periods apply to all claims related to the condition or event eg the maternity waiting period will apply to all claims relating to maternity for the mother and all claims for the new born infant from the time of birth until the waiting period has expired

• The 12 month pre-existing waiting period is applied at member level depending upon the member’s disclosure of pre-existing medical conditions at the time of application for cover

6. ExclusionsIn order to ensure the long term sustainability of Fusion™, certain exclusions apply. We list the main exclusions below – for full details, please refer to the policy document or contact us for a copy thereof:

• Day-to-day claims, unless specified

• Claims not approved by, or excluded by or paid as an ex-gratia by your medical aid

• Co-payment/deductible that is not a fixed rand amount (excludes oncology co-payments)

• Any penalty co-payment, deductible or limitation applied to your medical aid benefits for non-adherence to rules or authorisation procedures (unless specified in these benefits)

• Specialised Dentistry such as implants, crowns, bridges, orthognathic surgery, etc (does not apply to basic in-hospital dentistry, eg wisdom extractions or fillings for young children)

• Claims that are older than four months.

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7. PremiumsPremiums are established as follows for groups and individuals.

Premiums for Groups of 20 or more

KaeloXelus™ risk rates each prospective client group in accordance with demographic composition and medical scheme benefit option mix. It is, therefore, a requirement to obtain a quote for each prospective corporate client in order determine the premium for the group.

Membership data will be required for this purpose (please see section 8 for the data requirements).

Each Employer group’s premiums are revised annually based upon the claims experience of the group and the expected medical inflation for the coming year.

Premiums for Individuals and Groups < 20

There is a single standard premium for individuals and groups of less than 20 members, and is effective as from 01 January 2017. Please enquire with KaeloXelus™ to confirm the premium.

Members continuing with cover in their private capacity after resigning from an Employer group automatically revert to this standard individual rate. Only the balance of waiting periods will apply in such instances (if applicable) and a new policy number and schedule is issued.

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8. QuotationsWe will require a membership listing with the following information in order to provide a comprehensive group quote:

Based on the information a quotation will be provided with the specific terms and conditions outlined on page 3 of the quotation.

ChildrenAdultSpouse Benefit Option

DOB,Age orID No.

9. Application ProcedureApplication Forms

An Employer Application Form must be completed for groups.

Premium collections for groups can be done in one of the following 2 manners:

i. EFT Payment by Employer (i.e. payroll deductions by the Employer)

ii. Individual debit order deductions against each member’s personal bank account.

KaeloXelus™ requires each applicant to complete a Member Application Form (online or PDF e-Form) for voluntary membership.

For compulsory membership, no individual application forms are necessary but the employer must provide a comprehensive member listing with at least the following information:

- First name/s - Surname

- ID Number - Birthdate (if no ID number)

- Commencement Date - Medical Scheme

- Medical Scheme Option - Cell Phone Number

- E-mail address

For private members, no Employer Application Form needs to be completed.

Once KaeloXelus™ receives the individual application forms or the member listing, members will be loaded, activated and policy documents will be sent via e-mail to each member. A SMS is also issued to the member notifying them of the e-mail.

We can load a 2nd e-mail address on our system so that Intermediaries are copied when these policy documents are issued.

This must be requested for each client group by the Intermediary.

Billing statements are issued to all groups on the 16th of each month. Premiums are due by the 1st of each month. (This excludes debit order clients.)

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10. Claims ProcedureA claim form can be downloaded from our website - www.kaeloxelus.co.za

Once the claim form is completed and signed, the following supporting documents are required:

1. Claims Transaction Remittance from the Medical Scheme

2. Relevant Doctors Accounts

3. Hospital Account (first 2-3 pages only). For tariff shortfall claims only, the hospital account is not required.

Claims are processed continuously as and when received by KaeloXelus™ and payments are made on a daily basis.

An e-mail and SMS notification are issued to the member when:

• The claim is 1st captured;

• Requesting outstanding documentation (assuming they have not yet been provided);

• Authorising the claim payment.

NB: EFT payments can only be made to the principal member – by law we may not pay service providers.

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11. Contact DetailsMarketing / Presentations /

Quotes/ Training:

011 759 9600

enquiries@kaeloxelus.co.za

Call Centre Sharecall Number:

0861-4-93587

enquiries@kaeloxelus.co.za

General Queries

info@kaeloxelus.co.za

New applications and application queries

applications@kaeloxelus.co.za

New claims and claim queries

claims@kaeloxelus.co.za

Escalations

escalations@kaeloxelus.co.za

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12. Waiting Period Overview

New employees of voluntary groups of 20+ members and the member answers the

medical question as:

COMPULSORY GROUPS OF 20 OR MORE - NO WAITING PERIODS APPLY

For individuals, groups less than 20 or members who apply more than 2 months after commencing employment (unless within a window period concession),

applications will be treated as per section 5.3 above.

All the waiting periods will apply

- 12 month pre-existing &

12 month Maternity.

The pre-existing waiting period

will be waived. The 12 month Maternity

waiting period always applies.

Quick Overview

NO YES

BELOW APPLIES TO VOLUNTARY GROUPS OF 20 OR MORE MEMBERS

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