We will not compensate You for any Illness, condition, disease or injury, or the consequences of treatment, or resulting from, or associated with:

• Out-patient treatment other than specifically defined as covered.

• Hospital admissions for the purpose of diagnostic procedures.

Unless the policy makes provision for a specific benefit and is evident within the specific policy entitlement, any claim submitted will automatically be rejected.

We will not compensate You for any Illness, condition, disease or injury, or the consequences of treatment of, or resulting from, or associated with:

• An event not covered by this policy and/or falling outside of the policy’s benefits.
• Any claim that must be paid in terms of alternate proclaimed legislation, such as the Compensation for Occupational Injuries Act 90 of 1993, the Road Accident Fund Act 56 of 1996 and the Medical Schemes Act 131 of 1998.
• Any pre-existing condition, disease, disorder, or Illness, for a minimum of 12 (twelve) months. This will include any condition which existed prior to inception, or for which an insured person has sought or received medical advice or received treatment by a Registered Medical Professional or exhibited symptoms before inception of the policy.
• Any other condition for which a confirmed Waiting Period is applicable.
• Admission which is required for the purposes of investigative procedures or any other investigation only, unless specifically provided for in this agreement.
• Claims for advice on an on-going basis, routine physical examinations, or procedures of a purely diagnostic nature.
• Any illness, injury or consequence from alcohol, drug or substance intoxication, use, abuse, or addiction, directly or indirectly traceable to the insured being affected, permanently or temporarily. Claims may be considered where registered drugs are administered and prescribed by a Registered Medical Professional.
• Any Psychiatric or Psychological Condition or emotional or nervous conditions including, but not limited to, depression, insanity, psychosis, stress-related and affective disorders.
• Suicide, attempted suicide or any intentional or deliberate self-injury and/or self-exposure to danger or risk except to save a human life.
• Any skin/sub-cutaneous tissue and nail disorders, diseases, conditions and illnesses, inclusive of, but not limited to, lipomatous neoplasm and excision or biopsy related to the skin and/or subcutaneous tissue with the exception of a diagnosis of cancer being confirmed.
• Cosmetic Surgery where no clinical indication for treatment is present, including any treatment and costs resulting from these procedures unless specified as part of the benefit entitlement to this policy.
• Elective procedures with no clinical/medical indication including any treatment and costs resulting from these procedures unless specified as part of the benefit entitlement to this policy.
• Investigations, treatment, medication, or surgery related to any condition where the Member seeks advice, diagnosis and/or treatments outside the border of south Africa.
• BMI (Body Mass Index).
  – The additional charge by a Registered Medical Professional for the management of overweight and underweight patients with reference to the Body Mass Index (BMI).
  – The applicable BMI codes are 0018 and 0019 and are not covered on this policy.
  – The additional charge by a Registered Medical Professional for the management of overweight and underweight patients Body Mass Index (BMI), directly related to pregnancy and diseases that are non-lifestyle related and the Member is under medical care at claim stage, the Underwriter will pay those additional charges applicable.
• Investigations, treatment, or surgery related to infertility, artificial insemination, hormone treatment for infertility, or any other form of assisted reproduction.
• Procedures, medication, or devices for the purpose of contraception.
• Procedures related to the voluntary termination of a pregnancy.

Any Illness, injury or condition resulting from or directly associated with professional sport:

• Participation in any form of race or speed test, other than on foot.
• Involving any mechanically propelled vehicles or crafts.
• Participation in a sport or hobby that is defined by Underwriter as hazardous or dangerous except for scholars taking part in school activities.
• Participation as a professional sports person.

We will not compensate You for any Illness, condition, disease or injury, or the consequences of treatment of, or resulting from, or associated with:

• Any claim arising directly or indirectly from active involvement in war, invasion, act of a foreign enemy, hostilities (whether war be declared or not), civil war, rebellion, revolution, insurrection or political risk of any kind, or any act of any person acting on behalf of or in connection with any organisation, group or activity aimed at overthrowing any government by force or any deliberate act of terrorism or violence.
• Any riot, strike, or public disorder (including civil commotion, labour disturbances or lock-out) or any act or activity resulting in or calculated to bring about riot, strike, or such disorder.
• Active military duty, police duty, police reservist duty, civil commotion, labour disturbances, riot, strike, or the activities of locked out workers.
• The act of any lawfully established authority, police force, security force or any other local, provincial, or national body, in controlling, preventing, suppressing or in any other way dealing with any event referred to in the clauses above.
• Compensation in terms of the War Damage Insurance Act 85 of 1976.
• Nuclear weapons or nuclear material, ionizing radiation, or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel. For the purpose of this exclusion, combustion shall include any self-sustaining process of nuclear fission.
• Any loss arising from any contractual liability.
• Any consequential loss or damage whatsoever.
• Any attempt by you to commit an unlawful act.