Embed Size (px)
Citation preview
MAKING MEDICAL HEALTH AFFORDABLE SOUTH TO ALL AFRICANS FOR PEACE OF MIND WHEN FACED WITH MEDICAL NEEDS.
Mahala Loyalty Pty Ltd is a fully-edged FSP since 2004 and in partnership with Essential Med established in 2005 hereby bring you affordable and convenient medical insurance.
We want to make medical service in South Africa available to all salary-earning individuals; not a service only available to the elite few, but to all.
Together we strive to offer our members fresh thinking, agile service delivery, open communication and great personal service.
healthi n s u r a n c e
SAFETY TRACKERIncluded in All Packages
DRIVER PROTECTIncluded in Silver and Gold Packages
EMS (EMERGENCY MEDICAL ASSIST)Included in Silver & Gold packages
Mahala Loyalty Programme (Pty) Ltd. Authorised Financial Services Provider FSP number: 21961
Reg. no 2001/030145/07
DIRECTORS: Tanya Grobler (CEO), Len Lubbe, Fourie & Botha (Company Secretary)
Included in All PackagesMAHALA LOYALTY
Discounts, Points & Coupons galore!
Bail Assist, RAF claim assistance & Legal representation on the road Transport via Ambulance, Helicopter etc in an emergency
GPS tracking for your family
MISSING ASSISTIncluded in All packages
Find a missing person immediately with PSARU™
Essential Med is a registered Financial Services Provider. FSP No: 42980
Reg No: 2003/016142/06.
Essential Med DIRECTORS: Paul Cox (Managing Director), Earle Loxton, Danie Kok, Michael Jordaan, Michael Scott
MAHALA HEALTH INSURANCE powered by ESSENTIAL MED
Health insurance with included Lifestyle,
Day-2-day Primary Care and Hospital benets
from only R248 pm. (Family rates also available, see brochure)
An apple a day
keeps the Doctor
away! :)
CALL CENTRE 0860 021 070
Your
Mah
ala
Loya
lty c
ard
give
s yo
u a
WO
RLD
of
disc
ount
s an
d po
ints
at
mor
e th
an 2
000
Part
ners
na
tionw
ide.
Incl
uded in A
ll Pack
ages
MA
HA
LA L
OYA
LTY
See p
ack
age d
eta
ils for
benefit
incl
usi
on
Ben
efit
s:
CA
LL C
ENTR
E 08
60 0
21 0
70
SA
FETY
TR
ACK
ERIn
cluded in A
ll Pack
ages
Saf
ety
Trac
ker
is a
per
sona
l saf
ety
AP
P /
Mob
i des
igne
d to
kee
p yo
u an
d yo
ur fr
iend
s sa
fer
24/7
. It’s
pa
cked
with
feat
ures
for b
oth
day-
to-d
ay s
afet
y an
d re
al e
mer
genc
ies,
mak
ing
it th
e ul
timat
e sa
fety
tool
fo
r you
and
eve
ryon
e yo
u lo
ve. Y
ou c
an s
hare
you
r loc
atio
n vi
a an
arr
ay o
f sha
ring
optio
ns a
nd w
hen
you
are
in tr
oubl
e, th
e 91
1 A
lert
but
ton
will
imm
edia
tely
not
ify y
our f
riend
and
fam
ily m
embe
rs th
at y
ou n
eed
help
, and
let t
hem
kno
w w
here
you
are
(GP
S).
Sin
gle
Sin
gle
+ 1
Sin
gle
+ 2
Sin
gle
+ 3
Sin
gle
+ 4
Cou
ple
Cou
ple
+ 1
Cou
ple
+ 2
Cou
ple
+ 3
Cou
ple
+ 4
Pri
ncip
al M
embe
r A
ge o
f In
cept
ion:
Mem
bers
Cov
ered
:
18 -
64
yrs
Ove
r 55
yrs
Cou
ple
R24
8.00
R33
6.00
R41
3.00
R49
0.00
R49
0.00
R45
8.00
R57
9.00
R70
0.00
R81
0.00
R84
3.00
R89
8.00
R1 0
41.0
0
R1 2
28.0
0
R1 4
15.0
0
R1 4
81.0
0
Bro
nze
Silv
er
R29
2.00
R46
8.00
- -
Gol
d - -
R39
1.00
R47
9.00
R55
6.00
R63
3.00
R63
3.00
R74
4.00
R86
5.00
R90
9.00
R1 0
08.0
0
R1 0
30.0
0
R1 3
27.0
0
R1 5
36.0
0
R1 7
12.0
0
R1 8
77.0
0
R1 9
32.0
0
hea
lth
insurance
18 -
54
yrs
18 -
54
yrs
MIS
SIN
G A
SSIS
TIn
cluded in A
ll pack
ages
Wha
t do
you
do w
hen
a lo
ved
one
goes
mis
sing
? Th
e Pe
ople
Sea
rch
and
Res
cue
Uni
t (P
SA
RU
™) i
s a
24/7
cal
l cen
tre
help
line
spe
cial
ized
in p
rovi
ding
sup
port
in m
issi
ng p
erso
ns c
ases
. We
assi
st
wit
h th
e fo
llow
ing:
24/
7 C
all C
entr
e fo
r im
med
iate
ass
ista
nce,
Tra
uma
supp
ort a
nd a
spe
cial
ised
in
vest
igat
ion
team
to b
e di
spat
ched
imm
edia
tely
.
DR
IVER
PR
OTE
CTIn
cluded in S
ilver
and G
old
Pack
ages
Dri
ver
Pro
tect
add
ress
es t
he u
rgen
t de
man
d fo
r th
e le
gal
prot
ecti
on a
nd e
mpo
wer
men
t of
m
otor
ists
and
pas
seng
ers
rega
rdin
g th
e us
e of
a v
ehic
le.
The
Dri
ver
Pro
tect
Off
ers:
•
Com
preh
ensi
ve le
gal a
dvic
e &
ass
ista
nce
• A
24/
7, 3
65 d
ays
a ye
ar c
all c
entr
e se
rvic
e •
Ful
l RA
F cl
aim
s as
sist
ance
• L
egal
repr
esen
tatio
n in
the
Hig
h an
d M
agis
trat
e's
Cou
rts
natio
nwid
e •
Tra
fc
Off
ence
s ab
ove
R1
500
nes
• D
runk
en d
rivin
g• R
eckl
ess
driv
ing
• N
eglig
ent d
rivin
g •
Cul
pabl
e H
omic
ide
as a
resu
lt of
an
acci
dent
and
mor
e!
Ess
en
tial M
ed
is a
reg
iste
red
F
ina
ncia
l Serv
ices
Pro
vid
er.
FS
P N
o:
42
98
0
Your
wel
com
e pa
ck c
onta
inin
g yo
ur f
ull b
enef
it sc
hedu
le w
ill b
e po
sted
aft
er y
our
first
su
cces
sful
pre
miu
m c
olle
ctio
n by
Ess
entia
l Med
.
Incl
uded
Incl
uded
Incl
uded
Incl
uded
Incl
uded
Incl
uded
Incl
uded
Incl
uded
Incl
uded
Incl
uded
Life
styl
e B
ene
ts:
Bro
nze
Silv
erG
old
GP
Vis
its
Rad
iolo
gy &
Pat
holo
gy
Acu
te &
Chr
onic
Med
icat
ion
Unl
imite
d
Incl
uded
Unl
imite
d
Incl
uded
Unl
imite
d
Incl
uded
Not
incl
uded
Not
incl
uded
R2
000
Ben
et
Per
Polic
y P
er A
nnum
Not
incl
uded
Not
incl
uded
Not
incl
uded
Not
incl
uded
Not
incl
uded
Incl
uded
Not
incl
uded
Not
incl
uded
Up
to R
2 00
0 in
tota
l per
ann
um.
Up
to R
2 00
0 in
tota
l per
ann
um.
Man
aged
unl
imite
d de
ntis
t co
nsul
tatio
ns a
nd
proc
edur
es a
s pe
r for
mul
ary,
incl
udin
g cl
eani
ng,
pain
co
ntro
l, am
alga
m
llin
gs
and
norm
al
extra
ctio
ns.
Man
aged
un
limite
d de
ntis
t co
nsul
tatio
ns
and
proc
edur
es a
s pe
r fo
rmul
ary,
incl
udin
g cl
eani
ng,
pain
co
ntro
l, am
alga
m
llin
gs
and
no
rmal
ex
tract
ions
.
1 R
oot C
anal
Tre
atm
ent t
o th
e va
lue
of R
2000
per
ev
ent p
er b
ene
ciar
y w
ithin
a 1
2 m
onth
per
iod.
1
Cro
wn
per
bene
cia
ry to
the
valu
e of
R45
00 p
er
even
t w
ithin
a 2
4 m
onth
per
iod.
Res
in F
illing
s in
clud
ed.
Up
to R
75 0
00 p
er e
vent
for
sing
le, w
ith a
n A
OL
of R
150
000.
R15
0 00
0 pe
r in
cide
nt p
er fa
mily
w
ith a
n A
OL
of R
300
000.
EM
S in
clud
ed.
Up
to R
300
000
per e
vent
for s
ingl
e, w
ith a
n A
OL
of R
600
000.
R60
0 00
0 pe
r in
cide
nt p
er f
amily
w
ith a
n A
OL
of R
1 20
0 00
0. E
MS
incl
uded
.
1st 2
4 hr
s: U
p to
R10
000
Day
2: U
p to
R6
500
Day
3:
Up
to R
5 00
0 D
ay 4
Onw
ards
: U
p to
R
1 50
0. M
axim
um 2
1 da
ys’
tota
l ad
mis
sion
. Su
bjec
t to
a 3
mon
th w
aitin
g pe
riod.
1st 2
4 hr
s: U
p to
R10
000
Day
2: U
p to
R6
500
Day
3:
Up
to R
5 00
0 D
ay 4
Onw
ards
: U
p to
R
1 50
0. M
axim
um 2
1 da
ys’ t
otal
adm
issi
on.
Subj
ect t
o a
3 m
onth
wai
ting
perio
d.
In th
e ev
ent y
our D
octo
r adv
ises
:•
a C
-Sec
tion:
R35
000
ben
et a
vaila
ble.
• N
orm
al d
eliv
ery:
R25
000
is a
vaila
ble.
Subj
ect t
o a
12 m
onth
wai
ting
perio
d. 1
eve
nt p
er 1
2 m
onth
s.
R9
000
a da
y w
hile
adm
itted
for
a c
onr
med
D
read
Dis
ease
and
up
to th
e m
axim
um b
ene
t lim
it of
R35
0 00
0 w
ill b
e pa
id o
ut a
ccor
ding
to
the
stag
ing
of th
e di
seas
e.
Free
Sin
gle
Visi
on L
ense
s an
d fra
mes
ev
ery
24 m
onth
s.Fr
ee S
ingl
e Vi
sion
Len
ses
and
fram
es
ever
y 24
mon
ths.
Free
S
ingl
e or
B
i-fo
cal
lens
es
and
fr
ames
ev
ery
24 m
onth
s.
Den
tistr
y
Opt
omet
ry
Spe
cial
ist
Acc
iden
t
Illne
ss
Mat
erni
ty
Dre
ad D
isea
se
Cas
ualty
War
d
Day
-2-D
ay B
ene
ts:
Hos
pita
l Ben
ets
GP
Vis
its:
R25
0 re
imbu
rsed
if N
on-N
etw
ork
GP
is u
sed.
Rad
iolo
gy &
Pat
holo
gy:
With
in p
rovi
ded
netw
ork
(bas
ics)
.
Acu
te &
Chr
onic
Med
icat
ion:
An
exte
nsiv
e lis
t of
acu
te a
nd c
hron
ic m
edic
atio
n is
ava
ilabl
e.
30 d
ay w
aitin
g pe
riod
appl
ies
to a
cute
& 6
mon
th w
aitin
g pe
riod
appl
ies
to c
hron
ic.
Acc
iden
t: N
o w
aitin
g pe
riods
are
app
licab
le to
eve
nts
that
are
rela
ted
to a
ccid
ents
. Em
erge
ncy
Med
ical
Ser
vice
s ar
e au
tom
atic
ally
incl
uded
. AO
L =
Ann
ual O
vera
ll Li
mit.
EM
S =
Am
bula
nce
trans
port
to th
e ne
ares
t med
ical
faci
lity.
Illne
ss:
Incl
uded
ON
LY in
the
Gol
d pa
ckag
eSt
ated
Con
ditio
ns a
mou
nts
paid
reg
ardl
ess
of a
dmis
sion
day
s, b
ut n
ot in
add
ition
to th
e D
aily
Illn
ess
Ben
et.
Cer
tain
pro
cedu
res
no lo
nger
req
uire
ext
ende
d pe
riods
of
adm
issi
on. F
or th
is
reas
on w
e ha
ve c
over
for
spec
ic
even
ts:
• H
erni
a: R
20 0
00 •
App
ende
ctom
y: R
35 0
00 •
Gal
l / K
idne
y: R
35 0
00 •
Mis
carr
iage
:
R10
000
. A 1
2 m
onth
wai
ting
peri
od is
app
licab
le to
the
stat
ed b
ene
ts.
• H
yste
rect
omy:
R45
000
. A 2
4 m
onth
wai
ting
perio
d is
app
licab
le.
Cas
ualty
War
d: F
or th
ose
afte
r ho
urs
emer
genc
es th
at a
re n
ever
pla
nned
for
and
don’
t req
uire
ad
mis
sion
, we
offe
r ge
nero
us c
over
to h
elps
pay
for
cost
s at
Cas
ualty
. 30
day
wai
ting
perio
d if
due
to ill
ness
.
Dre
ad D
isea
se: H
eart
atta
cks,
Cor
onar
y H
eart
h D
isea
se, S
troke
, Can
cer a
nd K
idne
y Fa
ilure
are
a
few
of t
he c
ondi
tions
that
are
cov
ered
by
this
ben
et.
12 M
onth
s w
aitin
g pe
riod
appl
ies.
Spe
cial
ist:
If y
our
doct
or r
equi
res
you
to b
e se
en b
y a
Spec
ialis
t, an
ann
ual b
ene
t am
ount
is
avai
labl
e to
hel
p co
ver t
hese
cos
ts. A
90
day
wai
ting
perio
d ap
plie
s.
Opt
omet
ry: Y
our O
ptom
etry
ben
et i
nclu
des
an e
ye te
st p
er b
ene
ciar
y. 1
2 m
onth
wai
ting
perio
d ap
plie
s, a
vaila
ble
from
Spe
csav
ers.
Den
tistr
y: T
hese
ser
vice
s ar
e ob
tain
ed f
rom
an
Esse
ntia
l M
ed n
etw
ork
regi
ster
ed p
rovi
der.
6 m
onth
wai
ting
perio
d ap
plie
s.
Term
s
Incl
uded
Incl
uded
Incl
uded
hea
lth
insurance
Pri
ncip
al M
embe
r A
ge o
f In
cept
ion:
18 -
64
yrs
18 -
54
yrs
18 -
54
yrs
Mah
ala
Loya
lty
Saf
ety
Trac
ker
Mis
sing
Ass
ist
Dri
ver
Pro
tect
EMS
(Em
erge
ncy
Med
ical
Ser
vice
s)
Incl
uded
Incl
uded
Incl
uded
- -
GP
Vis
its, R
adio
logy
& P
atho
logy
: A
30
day
wai
ting
perio
d ap
plie
sfo
r th
ese
bene
ts.
0860
021
070
NAME:
AGENT DETAILS (FOR OFFICE USE ONLY):
SURNAME:
AGENT CODE:
CONTACT NO.healthi n s u r a n c e
CALL US: 0860 021 070 | EMAIL: [email protected] | WWW.MAHALAS.CO.ZA
ID/PASSPORT NUMBER
SURNAMEFIRST NAMES
CELL PHONE MARITAL STATUS
PLEASE SPECIFY ADDRESS FOR CORRESPONDENCE POSTAL HOME
ID/PASSPORT NUMBER
SURNAMEFIRST NAMES
Any pre-existing conditions not disclosed on application, may result in the policy being cancelled with immediate effect, with no refunds. This pertains to main member as well as to dependants.
SPOUSE/PARTNER: A person to whom the principal applicant is either married or has a committed and serious relationship with, similar to that of a marriage in which there is mutual and emotional support and a shared household, irrespective of the gender of either party.
DEPENDANTS: Children or other immediate family members in respect of whom the principal member is liable for care and support. Maximum age of child dependent is 21, unless the dependent child is studying full time or is mentally or physically handicapped and fully dependent on the principal.
GENDER M FINITIALSTITLE (DR, MR, MRS, MS)
POSTAL ADDRESS
RESIDENTIAL ADDRESS
POSTAL CODE
POSTAL CODE
1. POLICY HOLDER INFORMATION
2. MAIN MEMBER INFORMATION
D1
1. Currently receiving treatment of have received treatment for any medical/dental condition?
2. Concerned about/aware of any condition which may require medical/dental attention?
3. Currently using any medication?
4. Pregnant?
5. Have you applied for life insurance in the past 5 years for which you have been medically underwritten?
6. Has your health deteriorated since you last applied for this policy?
7. Have you ever suffered from, or do you currently have any of the following?
7.1 High blood pressure
7.2 Diabetes
7.3 Cancer or any kind of growth
7.4 Heart attack or heart disease
7.5 Shortness of breath
8. Have you, your spouse or any sexual partner been tested for or received treatment or medical advice
in respect of AIDS or conditions related to AIDS or the HIV virus, or are you waiting for a test result?
9. Do you take regular (daily / weekly) prescription medication for any illness or disease?
10. Have you been off work for an illness or accident longer than 3 consecutive weeks in the last 2 years?
4. MEDICAL RELATED QUESTIONS:
SURNAMEFIRST NAMES
ID/PASSPORT NUMBER RELATIONSHIP
GENDER M F
INITIALS
SURNAMEFIRST NAMES
ID/PASSPORT NUMBER RELATIONSHIP
GENDER M F
INITIALS
SURNAMEFIRST NAMES
ID/PASSPORT NUMBER RELATIONSHIP
GENDER M F
INITIALS
SURNAMEFIRST NAMES
ID/PASSPORT NUMBER RELATIONSHIP
GENDER M F
INITIALS
SURNAMEFIRST NAMES
ID/PASSPORT NUMBER RELATIONSHIP
GENDER M F
INITIALS
3. DEPENDENT INFORMATION
MM D1 D2 D3 D4 D5 NO
D2
D3
D4
D5
Q. no
Q. no
Member
Member
Insurer Name
Condition / impairment detail Doctor (Initial & surname) On treatment?Last symptoms
(date)
Date applied
Fully recovered?
If you ticked “YES” to question 5 - 6 in the Medical Questions Section, please provide us with more detail below:
If you ticked “YES” to question 7 - 10 in the Medical Questions Section, please provide us with more detail below:
1. If you do have an existing medical aid or medical insurance, will you be cancelling it and replacing it with this Policy?
2. Please provide the details of the medical aid or medical insurance if you are retaining it
5. EXISTING MEDICAL SCHEME / HOSPITAL PLAN
6. POLICY OPTIONS & FEES
7. DEBIT ORDER, AUTHORISATION & SIGNATURE
Single Member
Single Member + 1 Child
Single Member + 2 Children
Single Member + 3 Children
Single Member + 4 Children
Couple
Couple + 1 Child
Couple + 2 Children
Couple + 3 Children
Couple + 4 Children
Over 55 years
Couple
BRONZE SILVER GOLD
R248.00
R336.00
R413.00
R490.00
R490.00
R391.00
R479.00
R556.00
R633.00
R633.00
R292.00
R468.00
R458.00
R579.00
R700.00
R810.00
R843.00
R744.00
R865.00
R909.00
R1 008.00
R1 030.00
R898.00
R1 041.00
R1 228.00
R1 415.00
R1 481.00
R1 327.00
R1 536.00
R1 712.00
R1 877.00
R1 932.00
I / We hereby request “instruct” and authorise you to draw against my / our account with the below mentioned bank (or any other bank or branch to which I / we may transfer my / our account) the amounts (as indicated in point 5 above) or any other variable amount pertaining to this agreement. This being the amounts necessary for the settlement in respect of my / our purchases / agreement. These withdrawals from my / our bank account by you shall be treated as though it has been signed by me / us personally.
I/we understand that the withdrawal hereby authorized will be processed by Insurance Outsourcing Managers (IOM) (Pty) Ltd. And I/we also understand that the details of each withdrawal will be printed on my bank statement. I/we agree to pay any bank charges relating to this debit order instruction. This authority may be cancelled by me/us by giving 30 (thirty) days notice, either telephonically or in writing. I/we understand that I/we shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force if such amounts were legally owing to you. Any increase to the amount due to an amendment in cover or in rates, will be communicated accordingly.
Authority and MandateOn the day of each and every month commencing on for the amount of R . In the event that the payment day falls on a Saturday, Sunday or recognized South African public holiday, the payment day will automatically be the very next ordinary business day.MANDATE: I/we , ID number acknowledge that although this Authority and Mandate may be cancelled by me/us, such cancellation will not the Agreement. I/we shall not be entitled to any refund of amounts which Essential Med have withdrawn while this authority was in force, if such amounts were legally owing.
AcknowledgementI warrant that I have been provided with all the intermediary, insurance and benet details.I warrant that all details and facts herein are accurate and properly disclosed, even if completed by the intermediary or representative on my behalf.I understand that the benets offered are risk benets only and that there are no surrender values.Failure to pay premiums will result in benets lapsing.I acknowledge that this is a Health Insurance Policy and that the benets are not similar or a replacement to that of a Medical Aid.I am satised that the plan chosen by me, best suits my needs.I understand that applications are subject to approval and that Essential Med reserves the right to decline an application.
ACCOUNT HOLDER
ACCOUNT TYPE
INITIAL & SURNAME
VOICE RECORDING REFERENCE DATE SIGNATURE
INCEPTION DATE DEBIT ORDER DATE 1st 15th 25 th
ACCOUNT NUMBER
BANK BRANCH CODE
healthi n s u r a n c e
CALL US: 0860 021 070EMAIL: [email protected] | WWW.MAHALAS.CO.ZA
MY FINALPREMIUM IS:
R
