Yebo Doctor Terms & Conditions & Package Wording

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Welcome to the Yebo Doctor family.

 

Listed below is everything that you need to know about what your Yebo Doctor Package entitles you to.

Introduction


The GP and OTC benefits are administered by ASTERIO HEALTH
Important Information: ASTERIO HEALTH and AFRICAN UNITY have been granted exemption in terms of Section 8(h) of the Medical Schemes Act 131 of 1998 for this product. This is not a medical scheme and the cover is not the same as that of a medical scheme. This policy is not a substitute for medical scheme membership. The basis of Insurance is to put the policyholder and or beneficiary back in the same position they found themselves in prior to the event occurring. Therefore, Asterio Health will not pay claims to any policyholder where it is deemed to be enriching the policyholder and or beneficiary outside of the deemed definition of insurance.


Where an member is covered in terms of a statutory body such as the Compensation for Occupational Injuries and Diseases or the Road Accident Fund or in the case where a member is covered by a Medical Aid as defined in the Medical Schemes Act 131 of 1998, or their successors, in relation to an Accident, this Policy will only be obliged to cover amounts that the Insured may be liable due to shortfalls incurred and up to the maximum Accident Benefit amount

 

 

Medical Advice, GP Visits & OTC

 

Yebo Doctor gives clients quick and easy access to a qualified medical team of doctors and nurses anytime, anywhere. The service is available via a smartphone, desktop computer USSD or mobi-site where clients can use a text chat facility. Service includes authorised GP visits to a network of doctors. These benefits are available in the event of an acute illness or injury.

ASTERIO HEALTH have contracted with Yebo Doctor to provide assessment and authorization services relating to GP Visits and Over the Counter medicine benefits. All benefits related to these services are effective under the following conditions and processes:
a. Over the Counter Benefit – all benefits must be assessed by Yebo Doctor and in line with the protocols will authorize up to R100 per authorized amount per month with an overall limit of R1000 per annum per policy holder.
b. GP Consultation Benefit – should a GP consultation be required; Yebo Doctor will assess in line with protocols. If a GP visit is authorized, Africa Assist will establish where the relevant Network Provider is, contact the provider to set up the appointment and ensure that the benefit amount of R400 is paid to the provider.
c. Benefits available only if and when:
1. Pre-authorized by Africa Assist.
2. Guarantee of payment (GOP) issued to Network Provider by Yebo Doctor.
3. Pre-authorization and Guarantee of Payment (GOP: Asterio Health follows a ‘Best of Practice’ methodology in providing benefits within our treatment guidelines and protocols.

The benefit amount is not related to the specific cost of any medical treatment. Claims will be assessed in accordance with best practice clinical guidelines and protocols as determined by Asterio Health from time to time and does not require notification to policyholders.

Inclusive:

 

  1. Authorised GP visits (6 per annum)

  2. Authorised Dentist Visit (including extraction or filling once a year)

  3. Medical Health information and symptom assessment

  4. Childcare advice and support.

  5. Advise on managing chronic illnesses

  6. Stress management 

  7. Flu vaccine once a year

  8. Maternity program registration providing ongoing advice and support.

  9. Emergency ambulance services

  10. Limited Over the counter medication

Due to the Corona Virus lock down and the general concern about people moving around, we are offering members assistance with consulting a doctor via video conferencing. We have a number of doctors who are participating in this initiative and it will work as follows:

 

  1. When a member contacts us, we will assess the circumstances, triage the problem and where necessary authorize a doctor/GP consultation

  2. If a member should prefer a video consultation, we will arrange an appointment for the member

  3. We will arrange direct payment to the doctor

  4. Members can be provided with a script & can be referred to a laboratory for tests

  5. The doctor may refer the member for a face to face consultation if he believes that a physical examination is necessary

  6. The member will require access to a smart phone or access to a computer with WiFi/Data.

 

Referrals to:

  1. Closest Medical facilities

  2. GP’s within the client’s area

  3. Closest Medical Transport

  4. Health Specialists

Advice Lines:

24 Hour Medical Advice

Pregnancy Advice

Mom and Baby Line

Nutrition Advice Line

Diabetes Advice Line

Chronic Medication Advice Line

Teenager Advice Line

Gogo Advice Line

Medical Transportation:

In the event of a client’s involvement in a medical emergency, Yebo Doctor will arrange and coordinate the most appropriate method of emergency medical transportation. Clients will be transported to the nearest medical facility capable of providing adequate care.

Members who have additional cover from a medical aid  medical insurance plan that will cover the cost of being taken to a private facility will be taken to one. Should a member not have any additional cover they will be taken to the closest government medical facility.

Qualify: This service can only be used by registered members.

 

Activation: 

Step 1:

Access via Calling/Whatsapp/USSD

Step 2:

Call Yebo Doctors/ Nurses anytime day or night and they will advise you on the best way to manage your condition

Step 3:

In an emergency Yebo Doctor will send an Ambulance to transport you to a hospital. Depending on the severity of the condition.

Step 4:

If our medical team refers you to a doctor we will make an appointment for you with a GP within our network.

 

As soon as a client contacts Yebo Doctor, one of the Registered Nurses will reply. If the question requires a specialist answer, the nurse will refer the client to the doctor on call. Where necessary, Yebo Doctor will recommend that the client attends a consultation with one of Yebo Doctors Network General Practitioners (GP’s). 

 

Terms:  Yebo Doctor's Nurses and Doctors do not diagnose illnesses or prescribe medication. They will direct the client to the most appropriate level of care, or may put the client in contact with a health professional who can advise on the next steps. 

 

Referral to Network of GP’s: As an added benefit, should the client be referred to one of the Yebo Doctor's Network GP’s for a consultation, the client may attend at no extra cost. 

 

Utilisation: Six GP consultations per year, when referred by the Yebo Doctor Medical Team.

Doctor Video Consultation

Due to the Corona Virus lock down and the general concern about people moving around, we are offering members assistance with consulting a doctor via video conferencing. We have a number of doctors who are participating in this initiative and it will work as follows:

 

  1. When a member contacts us, we will assess the circumstances, triage the problem and where necessary authorize a doctor/GP consultation

  2. If a member should prefer a video consultation, we will arrange an appointment for the member

  3. We will arrange direct payment to the doctor

  4. Members can be provided with a script & can be referred to a laboratory for tests

  5. The doctor may refer the member for a face to face consultation if he believes that a physical examination is necessary

  6. The member will require access to a smart phone or access to a computer with WiFi/Data.

 

 

Over-The-Counter Medication (OTC)

 

When the Nurse assesses the case she may recommend that the member can obtain medication to treat the symptoms presented. She will recommend medication that is freely available, over-the counter, from a pharmacy with assistance of the pharmacist. The member will be able to obtain the medication at no extra cost but limited to R100 per consult and R1000 per annum.

 

TELEPHONIC HIV & TRAUMA COUNSELLING

 

Qualified Professional Nurses and Counsellors are available to provide telephonic debriefing as well as face to face counselling

 

Telephonic debriefing is conducted by the qualified counsellors. Should the counsellor determine a need for additional face-to-face counselling, the customer will be referred to an appropriate Trauma Counsellor, within the network, nearest to the customer's work or home address.

 

Once the Customer has been referred he/she will be assisted in scheduling an appointment or should the customer prefer, the contact details for the centre will be provided in order to make own arrangements. In the event of the latter, the particular counselling/trauma centre will be notified of a possible counselling session to be scheduled.

 

HIV Exposure

 

Your first choice in immediate HIV Exposure & Trauma Assistance affords you, your employees and your loved one’s step-by-step emergency medical guidance, emotional support and daily case management in the immediate event of possible HIV exposure and/or a traumatic incident.

Traumatic incident includes:

  • HIV exposure

  • Rape

  • Witness to suicide

  • Robbery

  • Natural disasters

  • Immediate bereavement

  • Physical assault

  • Attempted murder

  • Mugging / theft

  • Vehicle accidents

 

 

What you get?

  • Access to 24-hour Care Centre

  • Access to advice regarding the location of Instant Medication and Testing

  • Access to advice regarding where a member can receive Anti-Retroviral Therapy & STI Medication

  • Access to where a member can get Face-to-Face counselling

  • Telephonic Support by specialist case manager

 

 

Our Affiliate Network includes:

  • Doctors

  • Nurses

  • Social Workers

  • Psychologists

  • Counsellors

  • Occupational Therapists

 

Yebo Doctor USSD  MEDICAL PANIC 

 

Turn a cell phone into an emergency assistance tool for road, home and medical emergencies.

 

1. Clients will receive a welcome SMS, which will highlight the benefit and indicate to save this as a speed dial.

 

2. Yebo Doctor PANIC SOS will be there to assist 24/7 no matter where the clients are. In any form of emergency where the policyholder is unable to contact Yebo Doctor telephonically by pressing the SOS Panic button on their cell phone, our emergency alarm center will contact the member back to assess their emergency needs.

 

3. At the time of receiving this alert in our alarm centre, all the client’s location details would have been populated into our case management system which will better assist our agents to send the necessary help to clients.

 

4. Yebo Doctor calls the client within 90 seconds of the Yebo Doctor system receiving the panic alert.

 

5. Yebo Doctor responds to any emergency by deploying the appropriate service providers, which may include police, the appropriate ambulance service, roadside assistance, home assistance, or where the client has specified that they have private services (such as a private security company), these private service providers will also be deployed. The call centre acts as crisis managers and will provide total care for the client, whatever their situation. With permission from the client, Yebo Doctor will contact a family member, colleague or friend to assist in the process where this is considered useful. Please note that any costs incurred except for those stated n the benefits of the package are for the members own account.

 

6. If there is no answer on the phone that generated the panic, Yebo Doctor calls the client back 3 times at 60 second intervals, 

 

7. After the third call with no response, Yebo Doctor protocol is to leave a voice message if able to do so.

 

8. In addition, Yebo Doctor sends an SMS to the member’s phone, which includes a message that reads:

 

“We have responded to your message and called 3 times”.

- Yebo Doctor provides an alternative number that the client can use to phone the call centre.

- We invite the client to panic again (which starts the entire process off again).

- Yebo Doctor will continue to assist the client until the situation has been resolved and the case closed.

Yebo Doctor has partnered with St John to make sure that if you need an eye test and glasses you can get one.

 

Each member can have a free eye test & and we will pay R 250.00 towards a first pair of glasses purchased from St John*.

This benefit will be provided only by St John South Africa.

Waiting period to get an eye test is 90 days from first subscription payment.

Clients that take this offer up will be compelled to use St John Eye Care services Eye Care supplier. Each member is entitled to one eye examination in a 12 month period.

 The twelve St John Eye Clinics are currently situated across six of the nine provinces in South Africa. We will be adding additional eye clinics and will add them as soon as they are available. Eye tests are only available in the areas where St John has an eye care clinic, in he areas they do not have eye clinic NO eye tests will be able to be given. Here is a list of the St John has eye care clinics:   Baragwanath Eye Clinic Bloemfontein; Cape Town; Durban; East London; Fish Hoek; Grahamstown; Kimberly; Port Elizabeth; Somerset West; Soshanguve, Westbury

Things to Note:

  1. Validation – we require the name and ID number of the person requiring assistance. Only members who have an ID number registered & paying Yebo Doctor have access to benefits.  Family members do not have benefits unless they are regsitered and active paying members of Yebo Doctor and although we will provide advice for children, for instance there are no financial benefits for them unless they are regsitered members.

  2. GP visits are only available during office hours Monday to Friday and some network GP’s are available on Saturday mornings. In general GP’s are not available over weekends. If we receive a call on a weekend or at night we will assess whether the member requires a GP visit and whether they can wait until the morning or Monday, if it is the weekend. If we think that they need to see a doctor urgently we will refer them to an ER or Hospital but there is no financial benefit for that. This is also the case for accidents where X Rays etc may be required and where, in our opinion, a hospital visit will be more appropriate.

  3. Waiting period for the dentist benefit is 90 days from first subscription.

We will assist in making GP appointments and will the text the doctor’s details to member

  1. Maternity – GP consultations are not available for routine check-ups or Sonars. GP consultations are only authorized if the member is actually ill and requires a doctor appointment.

  2. Transfer of funds for OTC medication is available during weekdays from 08h00 to 18h00 and Saturday Mornings from 08h00 to 13h00 due to banking restrictions.

  3. Flu vaccines are only available during Flu Vaccine season which is March to end of May. 2020 flu vaccines will only be available late March this year. We can extend to mid-June but vaccines take about two weeks to take effect and are not effective once winter starts. 

On signing up for Yebo Doctor you are accepting the terms and conditions of this package. A member is contracting to sign up for a minimum period of 12 months. Payments are made monthly in advance. If for any reason your payment does not go through you will not have any access to the benefits of the Yebo Doctor Service for the following month until your next payment is made in full. You may not be notified that you are no longer covered it is the member's responsibility to ensure payment is timeously made so that there is continuity of access to benefits. In order to terminate membership of Yebo Doctor we will require 30 days written notice after the initial 12 month period. Should we not receive notice your membership fees will renew for a further 12 months. The benefits and terms and conditions may change from time to time, please refer back for any updates. Please send notification of cancellation to cancel@yebodoctor.co.za

When contacting Yebo Doctor you will be asked to verify your membership. You will have to give your full name and ID number/passport number to identify yourself to the call centre agent as a member.

There are no exclusions for existing conditions. A person of any age may join as a Yebo Doctor member. A member may be a South African or non South African resident. A child will be charged the same price as an adult. A family may join and each person will pay the same monthly membership fee.

POLICY OF INSURANCE

Please ensure that you are familiar with the contents of all the documents and that all the detail noted on the Schedule is correct in every respect.

1. WHO IS THE MEMBER ?
The person who is indicated on the policy documents referred to as “You”, “Your”, “Policyholder” or “Insured Person”.
2. WHO IS COVERED BY THIS POLICY?
The MEMBER only as indicated on the Schedule of Benefits is covered.
3. WHEN WILL A CLAIM (BENEFIT) BE PAID?
As soon as:
a. We have confirmed your membership;
b. We confirm your premium payments are up to date;
c. On approval by Yebo Doctor following assessment prior to incurring costs.
d. All terms and conditions have been met;
e. All required documents have been received.
The applicable benefit will be paid directly to the service provider by Africa Assist or to the member if Africa Assist determine that this is necessary.
4. YOUR RESPONSIBILITIES TOWARDS THE POLICY
The policy is in force for as long as your premiums are paid up to date or until your policy is cancelled by you, or by us, giving 31 days (thirty-one) notice. This Policy is a fixed term of 12 (twelve) months renewable annually.
In order to have cover you need to:
a. Pay your premiums;
b. Provide us with true and complete information when you apply for cover, submit a claim or make changes to your policy. This also applies when anyone else acts on your behalf;
c. Not admit any fault, nor make any offer or settlement, without our written agreement;
d. Agree to comply with all our reasonable requests;
e. Use all reasonable care and take all reasonable precautions to prevent or minimize loss, damage, liability, injury or death;
f. Inform us immediately of any changes to your circumstances that may influence whether we provide cover, the conditions of cover or the premium we charge. This includes any changes to any information on the Schedule of Insurance or in regards to convictions for offences by any person covered under this facility relating to dishonesty, reckless and negligent driving or driving under the influence.
5. POLICY CHANGES
You have to advise us when your contact details change. If you wish to cancel, you must do so in writing by giving 31 (thirty-one) days, notice for cancellation.
Should you wish to cancel the policy with "immediate effect, we may, at our discretion, accept the immediate cancellation and refund the premium related to the month in which the cancellation was requested, less all administrative expenses liable, to you.
You may make changes to your Insurance policy at any time. Confirmation of the change will be sent to you in writing. We may amend your policy by giving you 31 (thirty-one) days’ notice. Notice can be given by fax, email or post/mail to the last known contact details we have on record.
6. CLAIMS
Unless the treatment or medicine costs are authorised by Yebo Doctor at the time, no claims will be assessed or received after the treatment date.
7. DISPUTED CLAIMS
After we inform you of our decision on a claim, we will allow you 90 (ninety) days to make representations to us about our decision. If we do not compensate you for a claim or a part of it, and you want to contest our decision, you must do so in writing and outline your reasons for the dispute. We will provide you with a written response within 31 (thirty-one) days. If you do not agree with the outcome of the appeal, you may refer the dispute to the Ombudsman for Short-term Insurance or serve legal process on us within 90 (ninety) days after the time we allow for representations on disputed claims. Should you not enforce
these rights your claim will be deemed prescribed/abandoned. You are afforded an additional 6 (six) months in addition to the 90 (ninety) days to take legal action.
8. FRAUD, MISREPRESENTATION, NON-DISCLOSURE & DELIBERATE ACTS
Your fully completed application form with the relevant disclosures, provided by you or on your behalf, forms the basis of our contract. This policy can be re-underwritten, declared null and void or terminated if any misrepresentation or non-disclosure is made regarding any detail that is material to this insurance. Any incorrect information may affect the validity of this contract.
We will not compensate you for a claim where you or anybody who acts on your behalf, deliberately causes a loss, damage or injury. All cover under this policy will be forfeited if you submit a fraudulent claim, or anyone acts fraudulently on your behalf to obtain compensation.
9. TERRITORIAL LIMITS
Cover for this policy is only valid within the borders of the Republic of South Africa.
10. CONSENT CLAUSE
The sharing of claims information and underwriting information (including credit information) by Insurers is essential to:
a. Enable the insurance industry to underwrite policies;
b. Assess risks fairly;
c. To reduce the incidence of fraudulent claims;
d. Protect the public interest in terms of limiting excessive premium increases.
You hereby waive any right to privacy of any insurance information provided by you or on your behalf, in respect of any insurance policy or claims you lodge. You also consent to this information being
disclosed to any other insurance company and/or verified against other legitimate sources or databases.
Any personal income or health information obtained shall not be used or sold commercially and data security measures are in place to ensure the confidentiality of data management, and contractual agreements. ASTERIO HEALTH shall ensure that its staff also abides by the provisions of this clause and to do all things necessary to enforce such compliance. We collate age band, income band, demographics and race statistics and all information will be for statistical and reporting purposes only.
11. GENERAL POLICY EXCLUSIONS
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, injury, or the consequences of treatment of, or resulting from, or associated with:
a. An event not covered by this policy and/or falling outside of the policy’s intention.
b. 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.
c. Claims for regular or routine medical treatment and advice; routine physical examinations or procedures of a purely diagnostic nature; follow up consultations; chronic illness script renewals; consultations or treatment for chronic pain.
d. Any treatment not specifically authorized by Africa Assist’s medical team utilizing established medical protocols
e. 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.
f. Any Psychiatric or Psychological Condition or emotional or nervous conditions including, but not limited to, depression, insanity, psychosis, stress-related and affective disorders.
g. Suicide, attempted suicide or any intentional or deliberate self-injury and/or self-exposure to danger or risk except in an attempt to save a human life.
h. Medication, drugs, prescriptions, consumables and equipment used with the exception of over-the-counter medication when referred to a pharmacy by Africa Assist. Devices, such as artificial joints, braces, crutches, dental implants including all forms of internal and external prosthesis as defined.
i. Investigations, treatment, medication or surgery related to any condition where the policyholder seeks advice, diagnosis and/or treatments outside the border of South Africa.
j. SPORT RELATED EXCLUSIONS:
Any sport related illness, injury or condition except for scholars taking part in school activities.
12. DEFINITIONS AND EXPLANATIONS
a. Accident: An event that occurs unintentionally and usually results in harm, injury, damage, or loss. Policy cover only extends to accidents occurring after inception of the policy.
b. Acute: A condition which is generally unforeseen, of rapid onset in nature, is severe and treatable, but does not last for a prolonged period and is therefore not chronic.
c. Africa Assist: The contracted assistance company to facilitate specific clinical and financial risk management services.
d. Beneficiary: A person(s) other than the policyholder of an insurance policy who is entitled to receive benefits.
e. Chronic medication, diseases and condition: In medicine, lasting a long time. A chronic condition is one that lasts 3 months or more. Chronic diseases are in contrast to those that are acute (abrupt, sharp, and brief) or subacute (within the interval between acute and chronic)
f. Consumable medical supplies: Non-durable medical supplies that:
i. Are usually disposable in nature;
ii. Cannot withstand repeated use by more than one individual;
iii. Are primarily and customarily used to serve a medical purpose.
g. Dependent: Someone who is dependent upon the policy owner for access to the benefits available within this policy.
h. Designated Service Provider (DSP): The hospital/ specialists/ network providers prescribed where you can obtain diagnosis and treatment benefits without co-payments or penalties. A penalty or co-payment may be applied by your Scheme if you choose not to use the Designated Service Provider.
i. Diagnostic: A procedure or test which is performed to find out what is wrong with a patient. Diagnostic procedures do not aim to treat or cure a condition but is informative and exploratory in nature.
j. ICD-10 Coding: The International Classification of Diseases is a diagnostic coding standard that was adopted by the South African National Department of Health in 1996.
k. Illness: A disease or period of sickness affecting the body, which warrants treatment at an emergency facility.
l. Individual: A single human being as distinct from a group or family.
m. Injury: An injury sustained in an unforeseen future event, caused solely and directly by violent, accidental, external and visible means independent of and untraceable to any other cause.
n. Insurance: A policy providing protection against a possible eventuality
o. Medication: a drug or other form of medicine that is used to treat or prevent disease.
p. Network – a designated list of general, specialist, hospital and or pharmacy practitioners.
q. Policy Owner / Policyholder: If you own an insurance contract or policy, you are a policyholder, also known as the policy owner. As a policyholder, you may also be the person covered by the policy.
r. Principal: The Signatory to the application for inception of the policy.
s. Psychiatric or Psychological Condition: Any kind of mental illness and disability. This includes all forms of major affective disorders, anxiety disorders, psychiatric conditions and all other mental disorders as outlined in DSM IV (a manual outlining the diagnosis of all psychological and psychiatric conditions).
t. Registered Medical Professional: A person legally licensed and duly qualified to practice medicine and surgery (other than the Insured or a member of the Insured’s immediate family). This includes people legally licensed, duly qualified and registered in the Specialist Register of the Health Professional Board of the Republic of South Africa and recognized as such by them.

30 Jellicoe Ave, Rosebank, Johannesburg, 2196

South Africa

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