Bastion Health Limited

Understanding health insurance can sometimes feel like learning a new language. To help you become fluent, we've compiled a glossary of key terms you'll encounter while navigating your health coverage. This handy guide is designed to demystify the lingo, making it easier for you to understand the details of your plan and the benefits available to you.

• Beneficiary – the Client and his registered family members who are eligible to benefit under the Medical Scheme and pursuant thereto the benefits of this Agreement.
• Child – a beneficiary’s biological or legally adopted son or daughter that is in their custody and that is not more than the age of 21 years.
• Covered Services – a service, supply, or procedure applicable to a Beneficiary under their chosen health plan.
• Eligible Dependent – a Beneficiary’s spouse and/or children.
• Emergency Condition – a sudden medical condition that manifests itself by symptoms of sufficient severity or seriousness such that the absence of urgent medical attention may result in serious disability or death.
• Excluded Services or Non-covered Services – healthcare services that are not applicable to the Beneficiary under their chosen health plan.
• Health Check – a thorough examination of all new Beneficiaries to determine the status of their medical health condition and create a medical record for them.
• In-network Hospital or Plan-Hospital – a healthcare provider that has entered into an agreement with the HMO to provide healthcare services to a Beneficiary under a specified health plan.
• In-Patient Treatment – sometimes called hospitalisation, refers to medical care that requires an overnight or extended stay in a hospital or another medical facility.
• Medical Scheme – the health insurance plan offered by the HMO and purchased by the client.
• Medically Necessary – healthcare services that a reasonably prudent physician would deem necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malfunctioning or malformed part of a Beneficiary.
• Out-Of-Network Hospital or Non-Plan Hospital – a healthcare provider not related to or affiliated to the HMO or a healthcare provider not available within the chosen health plan.
• Out-Of-Network Services – healthcare services provided to a Beneficiary by an Out-Of-Network Hospital or Non-Plan Hospital.
• Out-Patient Treatment – sometimes be called Day-Patient Treatment, refers to medical care that does not require an overnight hospital stay.
• Period of cover for New-borns – All new-borns (not registered under a plan) are automatically covered for the first 6 weeks, thereafter premium must be paid for cover to continue.
• Pre-existing Condition – an injury, illness, sickness, disease or other physical, medical, mental or nervous condition, disorder, or ailment that with reasonable medical certainty existed at the time of purchase of the Policy or prior to the purchase of the Policy. These are conditions that a Beneficiary already had, already knew about, should reasonably have known about or for which there were symptoms before the Policy was incepted.
• Premium – the agreed annual consideration paid by the Client to the HMO per Beneficiary per annum for all Covered Services rendered under the Medical Scheme, except the Excluded Services which shall be paid for separately.
• Utilization Report – a report detailing the total number of visits per Beneficiary, the diagnosis, treatment, and investigations conducted on a Beneficiary and hospitalization, if any.
• Waiting Period – the period when underwriting takes place. This begins with the intending member filling our client data form, the HMO doing the necessary documentation and sending the name of the member to a chosen healthcare provider. The standard waiting period is 14 days. Within the 14-day period both parties reserve the right to cancel the policy.