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Assault, Trauma & HIV Protection

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Assault, Trauma & HIV Protection

This is a 24-hour emergency assistance helpline, which will arrange for the necessary help a beneficiary may require in a situation where trauma and/or assault and/or HIV infection as a result of the assault occurs. Cover is only provided within the borders of South Africa.

Assault is defined as a bodily injury sustained by violent external and visible means. Beneficiaries will receive medical treatment for bodily injury. In the case of trauma, the beneficiary will be able to receive psychological counselling from a public trauma centrea private institution. A beneficiary may call the trauma line in the event of:

  • Rape
  • Hi-jacking
  • Child abuse
  • Death of close family member
  • Armed robbery and assault
  • Domestic violence and/or abuse
  • Kidnapping / abduction
  • Suicide of family members

The HIV-protection service provides beneficiaries with peace of mind because in the event of violent forms of assault such as rape or accidental exposure such as a needle prick with a contaminated needle, the beneficiary his/her family has access to hospital care, treatment and diagnostic regimes for the management of the consequences. The imminence of HIV/AIDS will often cause the trauma to be of a more intense nature therefore the beneficiary will also receive psychological counselling.

Trauma & Assault

  • A helpline that arranges the nearest local emergency assistance service for the beneficiary as well as providing emergency medical transport to the nearest, most appropriate
  • medical facility as a result of a bodily injury where necessary the beneficiary will be stabilised before transportation is provided (inter-hospital transfers are not included)
  • Professional resource nurses, maintaining a high level of service when manning the helpline
  • The resource nurses also assist with referrals to psychiatric consultations
  • Cover for assault includes R5 000 per insured person with a maximum of R10 000 per family per occurrence in respect of medical treatment for bodily injury
  • Cover for trauma includes R5 000 per insured person with a maximum of R10 000 per family per occurrence in respect of psychiatric consultations

HIV-Protection Treatment

This is a 24-hour emergency assistance helpline, which will arrange for the necessary help a beneficiary may require in a situation where HIV infection as a result of the assault occurs. Cover is only provided within the borders of South Africa. The HIV-protection service provides beneficiaries with peace of mind because in the event of violent forms of assault such as rapeaccidental exposure such as a needle prick with a contaminated needle, the beneficiaryhis/her family has access to hospital care, treatment and diagnostic regimes for the management of the consequences. The imminence of HIV/AIDS will often cause the trauma to be of a more intense nature therefore the beneficiary will also receive psychological counselling.

The HIV protection-treatment service enables the beneficiary to make use of, at his/her own discretion, the following services, which can be paid out of the defined benefit of the policy:

  • 24-hour access to trauma counsellors, providing telephonic trauma counselling as well as counselling for post-traumatic stress disorder
  • Three consultations (per incident) with a specialist, either a general practitioner, trauma-trained registered nursetrauma counsellor
  • Three HIV blood tests (per incident): one immediately after the incident and the second and third at six weeks and three months respectively (should the beneficiary be HIV positive at the time of the initial blood test, further testing is not covered).

Provided that exposure has been established, and strictly on the treating doctor’s orders, if the beneficiary is HIV negative (following a rapid test) he/she will also be provided access to:

  • A 30-day starter pack of antiretroviral medication
  • A seven-day course of STI (Sexually Transmitted Infections) medication
  • A ‘morning-after pill’ to prevent pregnancy in the case of rape
  • Registration for an HIV-management programme, where applicable
  • 24-hours-a-day, 365-days-a-year telephonic access to an HIV counselling centre for information, advice and support

Should the beneficiary be HIV positive at the time of the event, he/she will be provided access to:

  • 24-hours-a-day, 365-days-a-year telephonic trauma counselling
  • 24-hours-a-day, 365-days-a-year telephonic HIV counselling
  • Three consultations (per incident) with a specialist, either a general practitioner, trauma-trained registered nursetrauma counsellor
  • A seven-day course of STI medication
  • A ‘morning-after pill’ to prevent pregnancy

Procedure

The call centre is a 24/7 facilitation centre that has the infrastructure for beneficiaries suffering from trauma to have access to immediate assistance. The call-centre nurses take control of situations and manage the process of communication with individuals and service providers to refer the beneficiaries to an appropriate service provider

In the event of trauma / assault / HIV infection a beneficiary must:

Call the helpline and give details of their circumstances, any immediate dangers and their condition. The nurses will arrange for the necessary assistance, be it the police the nearest local emergency assistance services etc. The nurses will monitor the medical condition of the beneficiary. Should the situation develop into a medical emergency, the nurses will:

Arrange for emergency medical evacuation, either by roadair ambulance
Arrange for the beneficiary to be transported to a hospital with emergency facilities closest to the scene of the incident
Monitor the beneficiary’s transportation and condition

 

Claims Procedure & Requirements

The beneficiary will ideally be referred to a public trauma centre medical facility, but can also be referred to a private counsellor for counselling. The beneficiary contacts the call centre to report the incident telephonically, following the initial telephone counselling by the resource nurse and her referral – if necessary. Claim forms will be faxed mailed to the beneficiary to complete. The beneficiary pays for treatment and claims back expenses.

  • The beneficiary submits the following documentation:
  • Claim form and police case number (for assault)
  • Medical reports in the event of injury
  • Certified copy of the beneficiary’s identity document
  • Banking details of the beneficiary

Will review the above documents to make a decision on the validity of the claim if the claim is valid, Will reimburse the beneficiary Claims must be submitted within 30 days.

Requirements

The beneficiary must notify the call centre immediately following the incident
If the insurer repudiates any claim, the insurer will be relieved of liability unless summons is served within 90 days of repudiation

Exclusions

  • Compensation will not be payable as a result of the beneficiary’s:
  • Participation in any riot, civil commotion, labour disturbance, strike lockout or public disorder any act of activity which is calculated directed to bring these about
  • Wilful misconduct

Performance attempt to perform:

  • Any act on behalf of any organisation, body group of persons calculated directed to over throw influence any state government, any provincial, local tribal authority with force, by means of fear, terrorism violence
  • Any act which is calculated directed to bring about destruction damage bodily injury in order to further any political aim, objective cause, to bring about any social economic change in protest against any state government or any provincial, local tribal authority for the purpose of inspiring fear in the public or any section thereof

Should an HIV accidental-exposure claim not be reported within 48 hours (up to a maximum of 72 hours), One Loyalty cannot accept the claim for the HIV-protection medication, although Beneficiaries can still make use of the telephonic advice and trauma counselling this exclusion pertains to the fact that the antiretroviral medication or starter pack will no longer be effective after expiry of 72 hours after exposure.

The insurer will not be liable for:

  • Any claim which is in any respect fraudulent
  • Loss, damage or bodily injury deliberately caused by the beneficiary or any person acting in collusion with the beneficiary, consequential loss or damage except as specifically provided

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