The Scheme may consider the approval of ex gratia assistance in cases where treatment and care is clinically essential, but the member’s benefits have been depleted. There is no guarantee that an application will be approved and the criteria used by the Committee and its decisions remain final and cannot be disputed.
The Board shall not authorise payment for services other than those provided for in the Scheme rules but may, in its absolute discretion, upon written request by a member, authorise an Ex Gratia payment in respect of a benefit, upon proof that undue hardship would otherwise be imposed upon a member.
The cut-off date for the submission of applications is the end of April of the following year.
The following does not qualify for Ex Gratia:
- Stale claims (older than 120 days)
- Scheme exclusions
Applications for Ex Gratia are submitted to the Clinical Committee to make a decision. This may take up to a month.
If the application is approved, an Ex Gratia authorisation letter is sent to the member.