Focus on exclusions

The following details outline the exclusions pertinent to the Momentum Medical Scheme benefits.

Momentum Medical Scheme has established specific exclusions that apply to its benefits. It is important to note that the general exclusions mentioned here are not influenced by any specific exclusions. Unless the Scheme decides otherwise, and with the clear exception of medicines or treatments that have been approved and authorized through any health management program contracted with the Scheme, expenses related to the following circumstances will not be covered by the Scheme. However, these expenses may be claimed from positive Savings balances:

• All costs incurred during waiting periods and for conditions that existed at the time of application for membership but were not disclosed to the Scheme. This means that if a member has a pre-existing condition that they failed to mention when applying, any related medical expenses incurred during the waiting period will not be reimbursed.
• Costs that exceed the annual maximum limit set for each specific category, as outlined in Annexure B of the Scheme Rules. Each beneficiary is entitled to certain benefits according to the Scheme Rules, and any expenses surpassing these limits will not be covered.
• Injuries or health conditions that arise from intentional participation in riots, civil disturbances, warfare, invasions, terrorist acts, or rebellions. Such circumstances are considered high-risk and are not covered under the Scheme.
• Expenses related to professional speed contests or professional speed trials. The term "professional" refers to individuals whose primary income comes from participating in such events. Therefore, costs incurred in the course of these activities will not be reimbursed.
• Services rendered by healthcare providers who are not registered with the appropriate professional body established under an Act of Parliament. This exclusion emphasizes the importance of receiving care from accredited professionals to ensure quality and compliance with legal standards.
• Costs associated with holidays taken for recuperative purposes, regardless of whether they are deemed medically necessary. This includes expenses incurred at facilities such as headache and stress relief clinics.
• All costs for treatments where the efficacy and safety cannot be substantiated. This exclusion is in place to protect members from unproven medical practices and ensure that only effective treatments are covered.
• Expenses related to cosmetic procedures or treatments that are not directly linked to a medical condition, accident, or disease. This includes surgeries or treatments for purely aesthetic reasons, such as transsexual procedures.
• Costs associated with obesity treatments, which are generally not covered unless specified otherwise in the Scheme.
• Expenses related to suicide attempts that exceed the costs associated with three days of hospital management or six outpatient visits. This limitation aims to manage costs while providing essential care.
• Procedures such as breast reduction, breast augmentation, treatment for gynaecomastia, otoplasty, and blepharoplasty are excluded as they are considered cosmetic in nature.
• Medication that is not registered with the Medicine Control Council is not covered, ensuring that only approved and regulated medications are utilized.
• Costs for services provided by any institution, nursing home, or similar establishment that is not registered according to applicable laws, with the exception of state facilities or hospitals.
• Expenses for items like gum guards and gold used in dentures are not covered under the Scheme.
• Costs for frail care services are also excluded from coverage.
• Travel expenses incurred by members, except for those benefits that fall under Emergency rescue and International cover.
• Any costs deemed by the Medical Assessor to be not medically necessary or appropriate for the patient's healthcare needs will not be reimbursed.
• Missed appointments for which a beneficiary fails to show up will not be covered.
• Circumcision is excluded unless it is clinically indicated, as well as any contraceptive measures or devices.
• Reversals of vasectomies or tubal ligations (sterilization) are also not covered.
• Injuries resulting from substance abuse, including narcotics or alcohol, are excluded except for those that fall under the Prescribed Minimum Benefits.
• Infertility treatments that qualify as Prescribed Minimum Benefits will be covered if provided in state facilities, subject to specific conditions outlined in paragraph 4 of Annexure D of the Scheme Rules.
• Costs arising from injuries related to scuba diving at depths greater than 40 meters or cave diving will not be covered, reflecting the high risks associated with these activities.

Additional exclusions for International emergency travel cover

For members enrolled in the Evolve, Custom, Incentive, Extender, and Summit Options, additional exclusions apply to the International emergency travel cover, which is available for journeys lasting up to 90 days outside of South Africa. Momentum Medical Scheme will not be responsible for paying any benefits that directly or indirectly result from the following:

• Care or treatment associated with maternity, including emergencies, if the member is pregnant while traveling. This exclusion is important to consider for pregnant travelers who may require medical attention during their journey.
• Oncology care or treatment is excluded from coverage, which means that members will need to seek alternative arrangements for cancer-related care while abroad.
• Any treatment or care related to organ transplants is also not covered under this policy, reflecting the complex and high-cost nature of such procedures.
• Care associated with chronic renal failure is excluded, indicating that members with this condition should prepare for potential medical needs outside of South Africa.
• Injuries, illnesses, or emergency conditions that arise during a three-month waiting period or a twelve-month condition-specific waiting period will not be covered. Members should be aware of these waiting periods when planning their travels.
• Any insured individual traveling against medical advice, seeking medical attention, or traveling with a terminal condition diagnosed prior to the journey, and who is unfit to travel, will not be covered. This emphasizes the importance of adhering to medical advice before undertaking travel.
• Coverage will not be provided for any insured person who fails to meet the criteria outlined in the fit to fly questionnaire, as detailed in the Focus on International emergency travel cover.