The following exclusions apply to Momentum Medical Scheme benefits.
General exclusions mentioned in this paragraph are not affected by any specific exclusions. Unless otherwise decided by the Scheme (and with the express exception of medicine or treatment approved and authorised in terms of any health management programme contracted to the Scheme), expenses incurred in connection with any of the following will not be paid by the Scheme, but may be claimed from positive Savings balances:
- All costs incurred during waiting periods and for conditions which existed at the date of application for membership of the Scheme but were not disclosed;
- All costs that exceed the annual maximum allowed for the particular category as set out in Annexure B of the Scheme Rules, for the benefit to which the beneficiary is entitled in terms of the Scheme Rules;
- Injuries or conditions sustained during wilful participation in a riot, civil commotion, war, invasion, terrorist activity or rebellion;
- Professional speed contests or professional speed trials (professional defined as where the beneficiary’s main form of income is derived from partaking in these contests);
- Health care provider not registered with the recognised professional body constituted in terms of an Act of parliament;
- Holidays for recuperative purposes, whether deemed medically necessary or not, including headache and stress relief clinics;
- All costs for treatment if the efficacy and safety of such treatment cannot be proved;
- All costs for operations, medicine, treatments and procedures for cosmetic purposes or for personal reasons and not directly caused by or related to illness, accident or disease. This includes the costs of treatment or surgery related to transsexual procedures;
- Obesity;
- The costs for attempted suicide that exceed the costs of three days hospital based management or six outpatient contacts;
- Breast reduction and breast augmentation, gynaecomastia, otoplasty and blepharoplasty;
- Medication not registered by the Medicine Control Council;
- Costs for services rendered by any institution, nursing home or similar institution not registered in terms of any law (except a State facility/hospital);
- Gum guards and gold used in dentures;
- Frail care;
- Travelling expenses, excluding benefits covered by Emergency rescue and International cover;
- All costs, which in the opinion of the Medical Assessor are not medically necessary or appropriate to meet the health care needs of the patient;
- Appointments which a beneficiary fails to keep;
- Circumcision, unless clinically indicated, and any contraceptive measures or devices;
- Reversal of Vasectomies or tubal ligation (sterilisation);
- Injuries resulting from narcotism or alcohol abuse except for the Prescribed Minimum Benefits;
- Infertility treatment that is included as Prescribed Minimum Benefits will be covered in State facilities subject to paragraph 4 of Annexure D of the Scheme Rules;
- The cost of injury and any other related costs as a result of scuba diving to depths below 40 metres and cave diving.
International emergency travel cover additional exclusions
The following additional exclusions apply to the International emergency travel cover, which is available to members on the Evolve, Custom, Incentive, Extender and Summit Options for journeys of up to 90 days outside of South Africa.
Momentum Medical Scheme will not be liable to pay any benefit resulting directly or indirectly from:
- Care or treatment related to maternity care or if you are pregnant whilst travelling (including emergencies);
- Oncology care/treatment;
- Treatment or care relating to organ transplants;
- Treatment or care relating to chronic renal failure;
- Injuries, illness and emergency conditions sustained during a three-month waiting period or a twelve-month condition-specific waiting period;
- Any insured person travelling against medical advice, or to seek medical attention or advice, or with a terminal condition which was diagnosed prior to the insured journey, when he or she is unfit to do so;
- Any insured person who failed to comply with the criteria relating to the fit to fly questionnaire, as described in the Focus on International emergency travel cover.