Sapphire Plan

We are pleased to present to you our plan benefit summary and how the Savings Accounts operate. Detailed information on the benefits is obtainable from our membership guide and or the benefit limits.

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Medical Savings Accounts

This covers foreign and local primary care and outpatient treatment e.g. Doctors consultation, prescription drugs from the available balances. This also covers in-hospitalisation benefits.

Shortfall Cover

Where the available balance in members’ savings account is not sufficient the shortfall cover will make up the difference. Shortfall cover will be awarded if member has used up to annual savings balance.

Insured Benefit Cover

This will cover all high cost treatment benefits e.g. in hospital treatment, specialist treatment, laboratory and radiology, chronic illnesses [cancer, kidney failure, HIV/AIDS treatment, ARVs etc.)

BENEFITS

Member benefits are per membership year, they are effective the date the member/beneficiary joins the Fund. These benefits are paid up to an annual global limit. If the global limit is exhausted, the member pays the difference. First Mutual Health, reserves the right to recommend members and or beneficiaries to a less expensive treatment where benefit usage is excessive.

MEDICAL BENEFITS

Paid in full at AHFoZ rates up to a Private ward in a Private Hospital Paid in full in a Government, mission or municipal hospital up to an Executive Ward at Parirenyatwa Hospital In-hospital drugs are paid for in full Members on this plan are fully covered on MARS for life threatening conditions only All life threatening emergency admissions are fully covered General practitioners are paid in full at AHFoZ rates with an additional shortfall insurance cover Blood Transfusion Services Pathology & Radiology Services at Private, Mission or Government institutions Private or Government Specialist treatment services

MATERNITY BENEFIT

Paid in full at AHFoZ rates and there is shortfall insurance cover on the benefit Caters for delivery, hospitalisation and maternity care. Ante- and post-natal visits are limited to 9 & 5 respectively Ante-natal Ultra-sound Scans are limited to 2 per pregnancy

OPTICAL BENEFIT

Paid for in full up to annual optical limit at First Mutual Health Rates and thereafter every 2 years The optical benefit is accessed after pre-authorisation by the Fund The fund has agreements with a wide range of service providers

DRUG BENEFIT

The drug benefit is a family annual drug limit and covers registered beneficiaries of First Mutual Health at the Fund’s rate. The Fund has a drug facility arrangement with a wide range of pharmacies countrywide. Over the counter drugs are not covered under the drug benefit

DENTAL BENEFIT

Awards are paid in full at the Fund’s rates up to annual dental limit. It covers preventive and general dentistry including fillings, inlays, root treatment, crowns, bridges, implants, periodontics and orthodontic treatment at the Fund’s rates

PROSTHETICS AND APPLIANCES

Awards are paid up to Prosthetics & Appliance annual limit in full – Internal prosthetics – External prosthetics – Hearing and repairs – Nebulisers – Ostomy bags – Miscellaneous appliances Lifetime Limits – benefits are accessed once in a lifetime, paid in full up to annual limit – Glucometers – Hearing Aids

PSYCHIATRY SERVICES

Covers consultation by a specialist psychiatrist and is paid in full up to global limit

REHABILITATIVE SERVICES

Covers Clinical psychology, Social Work, Physiotherapy, Occupational and Speech Therapy. Awards are paid up to rehabilitative services annual limit

ALTERNATIVE SERVICES

It covers Osteopathy, Homeopathy, Chiropractic, Chiropody and Naturopathy where the suppliers are registered under the Alternative Therapies Act

FOREIGN TREATMENT

Treatment not available in Zimbabwe paid in full up to annual limit. Preauthorization is needed.

TRAVEL INSURANCE

It is available to members & non-members of the Fund on application

STUDENT COVER

Available to students from High School, Vocational training centres, technical and Teachers colleges through to university

CHRONIC DISEASES

First Mutual Health Chronic Disease covers all ailments e.g. Kidney Failure, Cancer, and H IV/AI DS and ARVS Note – members are required to seek pre-authorisation before accessing the benefit

OTHER SERVICES

Awards are paid up to an annual limit – Homes Providing Constant Nursing Care – Homes for the disabled – Road and Air Evacuation in Zimbabwe – Inter- and intra-hospital transfer – Family planning

WAITING PERIODS

Subject to waiver at the Fund’s discretion, the following benefits have waiting periods. Waiting periods are imposed on members joining the fund for the first time or with a lapse on membership. Waivers may be granted to members transferring from an AHFoZ affiliated Medical Aid business upon presentation of a certificate.

List of Waiting Periods


Four Months

  • Admission or treatment at a hospital (in-hospital)
  • Specialist treatment
  • Upgrading to a higher plan
  • MRI, CT Scans and nuclear medicine

Nine Months

Maternity benefit

Ten (10) Months

  • Homes providing constant nursing care
  • Specialist foreign treatment (pre-authorisation required)
  • Spectacle or contact lenses

Eighteen (18) Months [1 year 6 months]

  • Internal prosthetic devices
  • Haemodialysis
  • Chemotherapy
  • Chronic disease add-on

Forty-Eight Months [Four Years]

  • Orthodontic treatment
  • Ex-gratia drug award
  • Periodontics

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