Welcome to Pro Sano

Must I disclose full details of any pre-existing conditions that I may have been treated for
in the past?

Answer

Yes, it is imperative that full details of ANY pre-existing conditions, irrespective of when they occurred, are disclosed on your application for membership. It is important to note that your application for membership is deemed a contract between you and the Scheme, and therefore you must ensure that all information provided is as detailed as possible, and is true and correct at the time of signing the application form. A Scheme may, in terms of the Medical Schemes Act and the Rules of the Scheme, exclude pre-existing conditions from benefits for a period of time (up to a maximum of 12 months) or terminate the membership of a member should the Scheme be in a position to prove material misrepresentation and/or non-disclosure of factual information. The same applies to registration forms for dependant membership.

Please ensure that your membership application and/or dependant registration form is signed and dated, as the Scheme is unable to accept an application/registration which does not have a signature and/or a signed date.

Which of my dependants can be registered on the Scheme, how soon should I register them
and from when will the extra contributions be charged?

Answer

A spouse of partner – the member must be able to demonstrate that they are married to the person in terms of any law or custom, or alternatively that they are in a committed and serious relationship based on mutual dependency and shared and common household, irrespective of the gender of either party.
A dependent child, including a step child, legally adopted child, or a child placed in the custody of the member or his spouse (or registered partner) by a court of law or a state institution. Children over the age of 21 will pay adult rates from the month after they turn 21, unless they are studying. Student children will pay adult rates from the month after they turn 27.
The immediate family members, namely father, mother, brother or sister of the member, for whom the member is financially responsible for family care and support. (Eligibility of immediate family members is reviewed annually).

Should the member apply to the Scheme for registration of the aforementioned beneficiaries more than 30 days after they become eligible for dependant membership, the Scheme reserves the right to apply underwriting conditions/waiting periods in accordance with the Medical Schemes Act and the registered Rules of the Scheme.

Contributions for newborn babies, born on any day other than the 1st of the month, will be raised with effect from the month following that of the birth. This also applies to the registration of a spouse, where the date of marriage falls on any day other than the 1st of the month (kindly note that this only applies if the application for beneficiary membership is sent to the Scheme within 30 days of the date of birth/marriage). Please read this paragraph in conjunction with the previous paragraph.

It is important to note that the Scheme’s Rules do not make provision for third generation dependants to be registered, unless they meet the criteria as set for a dependent child noted previously.

It is the member’s responsibility to inform the Scheme of any changes which result in any of their registered beneficiaries no longer satisfying the conditions in terms of which they may be a dependant within 30 days of the occurrence.

I have changed options, and my new option does not offer a savings benefit.
What happens to any unused, accumulated savings on my old option?

Answer

You are entitled to claim this unused, accumulated savings benefit from the Scheme. If the member’s medical savings benefit was fully utilised at the time of the option change, then no refund will be due. It is also possible that a member may have over-utilised the savings benefit if they opt to change options or resign from the Scheme during a benefit year. This over-utilised savings benefit will then have to be re-paid to the Scheme.

The same principal applies to members who resign from the Scheme and they are not joining or planning to join another Scheme that offers a savings benefit. If the new Scheme does however offer a medical savings benefit, then members are lawfully required to have the unused, accumulated savings transferred to the new Scheme.

Members can contact Customer Services on 0860 109 558 or email us at contributions@prosano.co.za to enquire in this regard should they be unsure if they qualify for a savings refund once they have changed options or resigned from the Scheme.

What are the requirements should I wish to terminate my membership?

Answer

In terms of the Rules of the Scheme, membership may be voluntarily terminated upon giving the Scheme one calendar month written notice. This written notice must include the reason for termination and can be emailed/faxed/posted to the Scheme at the following contact details:

Email: membership@prosano.co.za
Fax: 021 957 8650
Post: Private Bag X97, Bellville, 7535

What is Pre-Authorisation?

Answer

Pre-authorisation is the pre-approval of any booked admission to a hospital, including the relevant treatment and/or procedure by a registered practitioner. All treating providers (GP, Specialist, Physiotherapist, etc.) during the hospital event need to be pre-authorised. In order to ensure that the Scheme approves the appropriate number of days for the hospital event, members must be aware that the service providers must provide the Scheme with all relevant clinical updates in good time. Details of the pre-booked procedures will only be released to the member or nearest relative, as the Scheme must ensure that they are aware of the various disclaimers, Scheme exclusions/prosthesis limits.

MRI and CT scans, as well as radio isotopes studies, must also be pre-authorised – for both in and out of hospital procedures.

Pre-authorisation should be obtained by the member or the dependant only.
1. The member number, dependant code and the date of birth of the person being admitted.
2. Admitting and treating doctor’s name and practice number.
3. The name and practice number of the hospital, clinic or radiologist.
4. Date of the admission and the date of the operation or procedure. ICD 10 code and the procedure or tariff code/s, obtained from the doctor.

Are organ transplants covered?

Answer

Yes, organ transplants are covered to a maximum for R150, 000.00 in a private hospital and at 100% of cost at a state facility (subject to PMB).

What is PMB?

Answer

Prescribed Minimum Benefits (PMB) is the minimum benefits that the Scheme is obliged to pay as per legislation. PMBs are defined by specific diagnosis and treatment categories.

What is covered from the Oncology Benefit?

Answer

The Scheme only covers Chemotherapy and Radiotherapy from the Oncology benefit.

Please note that once a member is diagnosed with cancer, they must register on the Scheme’s oncology program. Pro Sano has a Designated Service Provider (DSP) for all oncology treatment, namely ICON. All Pro Sano members must make use of ICON doctors for their oncology treatment.