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About Genesis
Benefits
Claims
Contributions
General
About Genesis
How much does Genesis have in reserve funds?
Currently Genesis has in excess of R200 million, which is more than 4 times the legal minimum required by the Medical Schemes Act.
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Who provides financial backing for Genesis?
The Medical Schemes Act prevents a Medical Scheme from borrowing money. It follows that no Medical Scheme has financial backing. The success of a scheme is dependant on various factors, including the structure of its benefits, pricing of its premiums, management of its day-to-day activities, the risk of its members and its solvency reserves.
All medical schemes maintain a pool of funds that is used to pay claims. The success of any scheme lies in the ability of a scheme to maintain that pool of funds at a level that is sufficient for its members' claims. Hence the solvency requirements of a scheme as required by the Medical Schemes Act.
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Genesis is a medium size scheme. What will happen to a Scheme's solvency if membership is doubled or more?
Contributions are calculated after assessing the likely claims pattern or risk profile of the membership. A provision for reserves is also built into the contribution. Therefore, an effect on the solvency reserve will only be felt if there is a marked deterioration in the risk profile of the membership. This is so because as contributions increase, so will the profitability of the Scheme and the contribution to reserves. During 2004, Genesis increased its membership by more than 70% and yet still maintained a solvency level well above the 25% minimum.
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What is a "solvency ratio"?
The Medical Schemes Act requires medical schemes to have reserves of at least 25% of the total contributions paid by members in a year. The higher the solvency ratio, the greater the ability of the scheme to pay your claims.
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Is Genesis financially sound?
Absolutely!
The best measure of this is the solvency requirements as required by the Medical Schemes Act. The Act requires a minimum solvency of 25 % to be maintained by all medical schemes. Currently Genesis has in excess of R200 million, which is more than 4 times the legal minimum required by the Medical Schemes Act.
As at December 2010, 50% of open medical schemes had solvency rations of less than 25%.
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What is the physical address of Genesis?
The Terraces
4th Floor
Black River Park
Fir Street
Observatory
7925
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What is a new generation scheme?
A new generation scheme differs from a traditional scheme in that the scheme is primarily concerned with the costs associated with in-hospital treatment and procedures. All out-of-hospital medical costs are paid from your day-to-day credit facility via Savings Accounts.
Essentially out-of-hospital costs are for your account and the Scheme merely provides the credit facility and administers the claims on your behalf.
As a member of a new generation scheme you are responsible for managing your out-of-hospital costs, while the Scheme provides for the higher costs associated with hospital care.
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Who owns Genesis?
As with all medical schemes, Genesis is owned by all its members. Members elect Trustees who act on their behalf. The Trustees form the management committee of the Scheme and are elected to serve in the best interest of all the members.
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Is Genesis a Company registered in terms of the Companies Act?
No, Genesis is a medical scheme registered during May 1995 in terms of the Medical Schemes Act.
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Benefits
What benefit do I get for internal prosthesis?
The benefit for internal medical/surgical appliances is limited to R30 000 per member family per annum on the Private, Private Plus and Private Comprehensive options, and 50% of cost up to R20 000 per member family per annum on the Private Choice option
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When does Genesis pay for MRI/CT Scans?
Genesis Medical Scheme will cover the costs of MRI/CT scans at 100% of Scale of Benefits if you are hospitalised with an acute/emergency medical condition and where, in the opinion of the Scheme, the motivation from the attending practitioner confirms that the scan is clinically indicated for the urgent assessment and treatment of that condition.
Scans which, in the opinion of the Scheme, could otherwise have been done out of hospital, will not be covered.
Requests for all scans need to be clinically motivated by the attending practitioner before commencement of the investigations.
Expressly excluded from payment are scans related to dental conditions, conservative back treatment, migraine and diagnstic purposes, unless pre-approved.
If you are a member of the Private Choice option you will have a co-payment of R 2 500 per scan with a limit of 2 scans per family per year.
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How does the Major Medical Illness ("MMI") benefit work?
The MMI benefit (for the treatment of cancer, stroke, motor neuron disease and organ transplant(s)) is designed to provide cover for expenses that are both in and out of hospital, or post-operative. The MMI benefit has an overall limit of R550 000 per member family per annum, with sub-limits for certain treatment protocols. Should you have specific questions about this benefit, please contact Genesis directly.
When does a claim become stale?
Claims received by Genesis later than the last day of the 4th month following the month in which the service was rendered, will be regarded as stale and will not be paid. Members must check their statement for missing claims. The Scheme cannot be held responsible for postal delays.
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How must I submit a claim?
Genesis will accept signed claims by the principal member via e-mail, fax, post or by hand. Claims can be scanned and e-mailed to
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or faxed to 021 447 4707.
Electronic claims submitted by approved service providers directly to Genesis are also accepted.
Each month a statement will be sent to each member that has claimed in that month. We encourage members to check that the services were in fact rendered to them or their dependants.
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How often does Genesis pay claims?
Claims are paid once a month.
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Must I pre-notify Genesis of hospital visits?
Yes, this policy is in place to help members who are subject to waiting periods and to assist the Scheme in managing costs associated with the hospital event.
Please phone 0860 10 62 05.
In emergencies members must notify the Scheme by no later than the first working day following such admission.
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What if I do not notify the Scheme before admission to hospital?
A co-payment of R3 000 will be levied on all qualifying hospital events that were not pre-approved.
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Must I pay the pharmacy and claim a refund from the Scheme?
No, approximately 97% of all pharmacies are linked electronically to Genesis and they are able to verify your membership on line. The pharmacy will claim directly from Genesis.
Other medical providers are able to confirm benefits with Genesis and there should be no need to pay upfront. Some doctors however do not accept any medical schemes and will insist on payment upfront. Genesis will refund you for qualifying expenses.
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Contributions
When are contributions reviewed?
Generally contributions are adjusted to cater for inflation etc. on the 1st of January each year.
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What are the contributions for 2012?
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General
When will waiting periods be imposed?
Not all new members are subject to a waiting period(s).
Waiting periods are applied by the Scheme after first assessing the health profile of the applicant. It is a measure to prevent people from joining a Scheme purely because they have to go to hospital in the very near future.
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I have not claimed once from the Scheme. I now want to cancel my membership. Do I get my contributions refunded to me?
No. Your medical scheme is a form of insurance providing cover in case you need it. Even if you do not claim, the Scheme is still at risk in case you do claim.
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My dependant (in college) is still dependent on me. Why must I pay an extra Adult Rate per month?
The Rules provide that any person over the age of 21 years no longer qualifies as a child dependant.
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My spouse/partner/dependant/principal member died. What should I do?
If a dependant dies then we only require the death certificate. If the principal member dies then Genesis would require a new application form.
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How do I go about adding a dependant?
You need to complete the "Adding Dependant Application" form (found on the forms page). If you are adding a newborn baby Genesis would require a copy of the birth certificate.
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What must I do to change my debit order details?
Obtain a debit order form (found on the forms page) and return the completed and signed form to the Scheme.
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Am I covered for overseas travel?
No, but most major credit card companies include emergency insurance when their card is used for payment of overseas travel. Check with your credit card company or travel agent.
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If I leave my employer must I resign from Genesis?
Your membership of Genesis is in your individual capacity and your employment has no affect on your membership. When you leave your employer, you may continue your membership of Genesis by simply advising us of this fact and making suitable arrangements for payment of your contribution.
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What do I need to do should I wish to cancel my membership?
A member may terminate his/her membership of the Scheme by giving written notice. All rights to benefits cease after the last day of membership (Rule 13.1.1). We will require one month's written notice for the Private Choice and Private options and 3 months written notice for the Private Plus and Private Comprehensive options.
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