Everything you need to know about your cover.

Lion Health is a health insurance product underwritten by Lion of Africa Life Assurance Company Limited and administered by Pan-African Managed Care (PAMC). It gives you access to day-to-day healthcare benefits, hospital cover, or both — depending on the plan you choose.

No. Lion Health is a health insurance product, not a medical aid. Benefits are insurance benefits paid in accordance with the policy terms and conditions. It is not regulated under the Medical Schemes Act and does not attract the medical aid tax credit.

Yes. Many members use Lion Health alongside their existing medical aid to cover everyday costs and bridge the gaps their medical aid leaves. The Hospital Plan applies a 3-day franchise if you are a medical aid member — cover begins from day 4 of a qualifying illness admission.

There are three plans to choose from:

• Day-to-Day Plan — covers everyday healthcare costs: private doctor visits, medication, dental, optometry, tests and more.
• Hospital Plan — covers hospital admissions, accidents, surgery, serious illness (Dread Disease) and maternity.
• Combined Plan — includes all Day-to-Day and all Hospital benefits in one policy at one monthly premium.

You have access to unlimited private doctor consultations within the PAMC network. Pre-authorisation is required after your 3rd consultation in a policy year. You also have access to the 24/7 WhatsApp Nurse line (Africa Assist: 060 550 4337) for health guidance — pre-authorisation applies after 6 nurse consultations per year.

Yes. Specialist consultations are reimbursed up to R2 060 per member (maximum R4 120 per policy per year), subject to a referral from a network private doctor and pre-authorisation. The specialist does not need to be in the PAMC network. Where a specialist submits claims directly, there's nothing further for you to do. Where they don't, simply pay the account and submit your claim for reimbursement. Any shortfall remains your responsibility. A 90-day waiting period applies.

The Day-to-Day Plan includes 2 dental check-ups per year, covering scaling and polishing, extractions and fillings, at the agreed network tariff. A 90-day waiting period applies.

Yes. You receive 1 eye test every 24 months and 1 set of glasses every 24 months, including standard lenses and a network frame. This benefit is available exclusively through the PPN network (Spec-Savers or Execuspecs). A 90-day waiting period applies.

Yes, for approved conditions on the Lion Health chronic medication list. Pre-authorisation is required and a 90-day waiting period applies. Cover is subject to the approved formulary.

Yes. Acute and over-the-counter medication is covered up to R1 340 per year (R155 per event). Cover is subject to the approved Lion Health formulary.

Yes. Basic pathology and black-and-white radiology are covered when referred by a network private doctor. No waiting period applies.

The Day-to-Day Plan covers 2 growth scans and antenatal medication and vitamins up to R120 per month for 9 months. A 10-month waiting period applies.

The Day-to-Day Plan does not include hospital admission benefits, ICU cover, surgery benefits or Dread Disease benefits. The plan does include an emergency/trauma room benefit of up to R5 000 per year. For hospital cover, see the Hospital Plan or Combined Plan.

The Hospital Plan pays stated daily illness benefits up to a maximum of R53 000 over a 21-day period:

• Day 1: Up to R10 000
• Day 2: Up to R7 500
• Days 3–4: Up to R5 000 per day
• Day 5 onwards: Up to R1 500 per day

Benefits are stated insurance amounts — they are not payment of your actual hospital bill. Admissions require authorisation. On approval, the benefit may be paid to the hospital in accordance with the Guarantee of Payment issued, or paid post-discharge on submission of a valid claim and supporting documentation.

The ICU Booster pays up to R15 000 per day for a maximum of 5 days in ICU. A 90-day waiting period applies for illness-related admissions.

The plan includes stated benefits for the following procedures:

• Appendectomy / removal of kidney stones: R30 000
• Ectopic pregnancy: R20 000
• Hernia: R25 000
• Gallbladder removal: R35 000

A 90-day waiting period applies. Pre-authorisation is required.

Yes — and there is no waiting period for accident benefits. The accident benefit provides up to R300 000 per person per accident, or R450 000 per family. Africa Assist issues a Guarantee of Payment directly to the treating hospital on your behalf. A casualty/trauma room benefit of up to R12 500 per year is also available.

The Dread Disease benefit covers heart attack, stroke, cancer, kidney failure, major organ transplant, paraplegia, blindness and chronic coronary heart disease. Benefits are paid according to severity grading and policy limits. A 180-day waiting period applies.

• Natural birth: up to R30 000
• C-section: up to R45 000
• Miscarriage: up to R15 000

A 10-month waiting period applies. Pre-authorisation is required.

A 3-day franchise applies. The first 3 days of a qualifying illness admission are not covered, after which benefits are available for up to 18 days per illness event at R1 500 per day.

Pre-existing conditions during the waiting period, elective and cosmetic surgery, fertility treatment and contraception, mental health disorders not caused by an accident, and other standard policy exclusions. Please refer to the policy wording for the full exclusions list.

The Combined Plan includes all Day-to-Day Plan benefits and all Hospital Plan benefits in one policy at one monthly premium. The benefits are identical to the standalone plans — they are simply bundled together.

Yes. Choosing the Combined Plan does not reduce or alter any individual benefit. You receive the full Day-to-Day and full Hospital benefits exactly as described above.

Yes. The following waiting periods apply across all plans:

• No waiting period: private doctor consultations, acute medication, pathology and radiology, accident benefits
• 90 days: specialists, dental, optometry, chronic medication, hospital illness admissions, ICU, surgery
• 10 months: maternity benefits
• 180 days: Dread Disease
• 12 months: pre-existing conditions

Any illness, injury, diagnosis, symptoms, treatment or medical advice that existed before your policy start date may be considered a pre-existing condition. These conditions are subject to a 12-month waiting period.

Yes. Dependants can be added at any time. Waiting periods apply from each dependant's own join date. Newborns should be registered within 30 days of birth to ensure seamless cover from birth.

Premiums are paid monthly in advance via debit order or stop order. A grace period applies until the 15th of the month.

If your premium remains unpaid after the 15th, continued non-payment may result in cancellation of your membership in accordance with the policy terms.

Yes. A lapsed policy may be reinstated within 2 months of lapsing. If missed premiums are not paid on reinstatement, your inception date will reset to the reinstatement date and standard waiting periods will apply again from that date.

DebiCheck is a debit order that you confirm electronically with your bank on a once-off basis, at the start of your contract, before it is processed to your account. Your bank will notify you via your banking app or USSD — approve it there to keep your premium collection active. See our step-by-step guide, by bank, at lionhealth.co.za/debicheck.

Where you have paid for eligible out-of-pocket medical expenses, submit your claim together with the required supporting documentation to claims@pamc.co.za within the applicable claim period. Qualifying hospital admissions require pre-authorisation and may be settled directly with the hospital upon approval.

No. Every claim is assessed individually against the policy terms, conditions, applicable waiting periods and benefit limits. We are unable to guarantee payment in advance of assessment.

The main exclusions include:

• Pre-existing conditions during the waiting period
• Suicide or self-inflicted injury
• Alcohol or drug-related incidents
• War, riots and terrorism
• Professional sports
• Hazardous activities
• Cosmetic or elective procedures
• Fertility treatment and contraception
• Mental health disorders unless caused by an accident

Please refer to the policy wording for the complete list.