Cimas MEDICAL AID SOCIETY
Membership Rules
(Issued in terms of Clause 5 of the Constitution of Cimas Medical Aid Society)
Together we make a difference
March 2013
1. Title
These Rules may be cited as the Cimas Medical Aid Society Membership Rules.
2. Application
(a) These Rules shall apply to all members of the Society, and are the sole
Rules of the Society. For the avoidance of doubt, all previous Membership
and Scheme Rules are hereby repealed. In particular, the Membership
Rules dated July 2010 are hereby specifically repealed.
(b) Should any doubt arise as to the meaning of these Rules, the
interpretation of the Board shall be binding on all members and member
firms.
(c) At its discretion and in the best interests of the members and in terms of
the powers vested on it by the Constitution, the Board shall have power
to amend, alter or change these and any Rules in any manner whatsoever.
(d) The Board may, at its discretion, develop additional rules for specific packages.
(e) All words and expressions purporting the masculine gender shall include the feminine and words signifying the singular shall
include the plural and vice versa.
(f) These Rules shall not apply to Special Schemes administered by the Society.
3. Definitions
In this Constitution unless inconsistent with the context -
"Benefits" means those services rendered by the medical, dental and allied professions which are claimable by members from the
Society.
"Board" means the Board of Cimas established in terms of the Constitution of Cimas Medical Aid Society.
"Cimas Constitution" means the Constitution of Cimas Medical Aid Society.
"Dependant" means dependant spouse, dependant child, dependant student and/or other dependant.
"Dependant Spouse" means the member's legal husband or wife.
"Dependant Child" means the member's child, stepchild, legally adopted child or child committed to the member's custody and control
by virtue of an Order of Court. Provided that such dependant child is under the age of eighteen (18) years, and is fully dependent on
the member.
"Dependant Student" means the member's dependant child who is over the age of eighteen (18) years and who is continuing unbroken
education at a recognized educational institution:-
Provided that such dependant student membership shall cease on the said dependant student attaining the age of twenty-five (25)
years unless the Board specifically approves of a continuation beyond such age.
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"Member" means a person admitted to membership of the Society in terms of its Rules.
"Member Firm" means a company, body corporate, special scheme, statutory
corporation, partnership, employer, or self employed person which or who contributes
as a member firm to the Society.
"Membership Year" means the period of Twelve (12) months commencing from the first
day of the month in which the member or dependant originally joined the Society.
"Other Dependant" means such other dependant person as the Board may, in its
absolute discretion, decide.
"Package" means Cimas products available to members and other products that are
developed from time to time.
"Pensioner" means a member of the Society who has reached Retirement Age and is now categorised under pensioner membership in
terms of 7. below.
"Retirement Age" means the age set by the Board, at its sole discretion, from time to time at which a member is deemed to have
retired from employment.
"Society" means Cimas Medical Aid Society.
"Special Scheme" means a medical scheme administered by the Society in terms of the Cimas Constitution.
4. Admission to Membership
(a) Members shall have the right to apply for membership of the Society for their dependants as is acceptable to the Board.
(b) All applications for membership, pensioner membership, or for the admission or deletion of dependants, whether from a firm or
from an individual, shall be made in such form as the Board may from time to time prescribe.
(c) The Board shall have complete and absolute discretion to accept or refuse:-
(i) any application for membership or pensioner membership, and
(ii) membership to a dependant person; and it shall not be bound to disclose the reason for its decision.
(d) Before accepting or rejecting any application for membership including that of a pensioner member, the Board may require such
applicant or any of his dependants to submit to a medical examination either by his own doctor or by a doctor or specialist
nominated by the Board and the costs of such examination shall be borne by the individual.
(e) (i) In all cases the benefits flowing from membership of the Society shall only accrue to a member and his dependants from the
date on which such member or dependant is deemed to be admitted to membership. For the avoidance of doubt any
waiting periods set out in the benefits summary schedule shall apply on admission to membership.
(ii) Membership of a newly-born child may be back-dated to its date of birth if the relevant application form and contributions
are received by the Society on or before the tenth (10) day of the second month following that in which the child is born.
(f) Every member or beneficiary shall prior to or immediately on admission familiarise themselves fully with the Constitution of the
Society, these membership rules, the relevant benefits of their chosen packages and the terms and conditions of accessing those
benefits. Every member shall be deemed to be aware of all these upon admission to membership.
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5. Individual Membership
(a) Admission to membership of the Society shall be open to all
persons who are under the Retirement Age.
(b) The Board may, at its discretion, admit to membership persons
who are above the Retirement Age on set terms and conditions.
6. Membership by Member Firms
(a) A firm may apply to join the Society as a member firm. The Board
may, at its discretion, admit such firm as a member firm.
(b) When a firm is admitted to membership of the Society, all present
and future employees of such member firm shall have the right to
apply for membership of the Society.
7. Pensioner Membership
(a) A pensioner who, immediately before reaching retirement age, was a member of the Society for a continuous period of ten (10)
years shall be entitled to apply for pensioner membership.
(b) A pensioner on pensioner membership shall pay contributions at such rates as approved by the Board from time to time.
(c) Upon the death of such pensioner, his widow who was a dependant member shall be eligible to apply for pensioner membership.
Provided that pensioner membership shall not be granted nor allowed to continue during regular employment but may be
resumed on termination of such employment.
(d) Where a pensioner takes up regular employment and the employer does not include medical aid as a benefit of employment for
his staff, the pensioner may be granted membership of the Society on terms and conditions and at a rate of contribution approved
by the Board.
(e) The rates of contribution approved by the Board in respect of pensioner membership shall vary among other things according to
the length of continuous membership with the Society completed by a pensioner immediately before attainment of retirement
age.
8. Termination of Membership
(a) A member or dependant shall cease to be a member of the Society-
(i) on his death;
(ii) on his resignation;
(iii) if he is expelled from the Society; or
(iv) if the membership of the member firm under which he is registered is terminated in terms of these Rules and the member
has not applied for individual membership in terms hereof.
(b) A member or dependant may be expelled from the Society -
(i) for breach or attempted breach of these Rules,
(ii) for any act attributable to the member which is detrimental to the interests of the Society,
(iii) for non-payment of contributions for three (3) consecutive months,
(iv) for any reason adjudged by the Board as good and sufficient for such action. In such event the Board will not be obliged to
disclose the reasons for its decision.
(c) Membership of the Society shall be terminated on one (1) month's notice in writing to that effect given by either a member,
member firm or the Society.
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9. Contributions
(a) Every member shall pay the Society, in respect of himself and his dependants, a monthly contribution prescribed from time to
time by the Board.
(b) The Board for good reason and at its sole discretion, may authorize reduced contribution rates in respect of children, students
and pensioners.
(c) All contributions are due and payable to the Society in advance by the Twenty Fifth (25th) day of each preceding month. For
example, the contributions for February are due by the 25 January. These shall have the supporting details and shall be in such
form as the Board may from time to time prescribe.
(d) Failure to pay contributions by due date shall render the member or member firm liable to expulsion from the Society or the
suspension of benefits.
(e) The Board shall give to all member firms and members one (1) full calendar month's written notice of any intended alteration in
the basis or scale of contributions. Such notice shall be deemed to have been received by a member, member firm and its
employees; seven (7) days after the dispatch thereof by unregistered cover to the address recorded in the books of the Society.
(f) Any member firm or member who is not prepared to accept the alteration in the basis or scale of contributions shall:-
(i) within fourteen (14) days from the date of receiving notice thereof, notify the Society in writing of such non-acceptance; and
(ii) on the date on which the altered basis or scale becomes effective, cease to be a member firm or member, as the case may
be, of the Society.
(g) Where there has been an erroneous overpayment of contributions, such overpayment shall be credited to the account of the
party concerned for future payment:-
Provided that the Board may, at its sole discretion order that the overpayment be refunded to the party concerned.
(h) The Board may, at its discretion, levy interest on all overdue contributions payments at the minimum lending rate prescribed by
the Society's bankers.
10. Benefits
(a) Every member of the Society shall be entitled to have the reasonable and necessary medical, dental and drug expenses incurred
by him and by each of his dependants as have been admitted to membership, defrayed in whole or in part by the Society in
accordance with a schedule of benefits laid down from time to time by the Board.
Provided that, if in the opinion of the Board such expenses have been incurred unreasonably or unnecessarily; or are excessive.
(b) The Board shall, in its absolute discretion, have the power to reject the claim in full or pay such amount as it may consider
appropriate, having regard to the circumstances of each individual case and without having to assign any reason therefore.
(c) In case of illness of a protracted nature, the Board shall have the right to require the patient to submit to a medical examination by
a specialist nominated by the Board and the cost of such examination shall be borne by the Society. If, in such case, the specialist's
advice is not sought nor acted upon by the member or patient, the Board shall have the right to refuse further benefits in respect
of the particular illness.
(d) In the case of a member or dependant whose claims constitute a constant drain on the funds of the Society; the Board shall have
the power in its sole discretion without assigning any reason therefore:-
(i) to exclude such member or dependant from any particular benefit;
(ii) to remove such member or dependant from membership of the Society; or
(iii) to pay such portion of the claim or claims as it deems fit.
Provided that, before putting into effect any such decision in terms hereof, the Board shall give the member one (1) month's
notice in writing of its intention.
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(e) The Board may from time to time fix a maximum amount of total benefits, or a
maximum amount of specific benefits, which shall be payable in respect of
expenses incurred by a member and his dependants in any one membership year.
(f) The Board may, in its sole discretion, having regard to the circumstances of each
individual case, pay such amount in excess of the Schedule of benefits as it may
consider appropriate.
(g) Expenses incurred as a result of the items listed below shall not be accepted by
the Society. However, the Board, in its sole discretion, has the power to waive
these provisions in special circumstances-
(i) reversals, by whatever means, of sterilisation operations;
(ii) treatment, the cost of which is recoverable in law from any other party,
body, source or in terms of a policy of insurance;
(iii) operations or treatment which, in the opinion of the Board, are not
essential, including operations or treatment of a cosmetic nature, whether
or not such operations or treatment have been advised on psychiatric
grounds;
(v) illness, or injury arising from or due to war, act of terrorism or rebellion;
(vi) medical examinations, inoculations and injections other than for diagnostic
or therapeutic purposes;
(vii) acupuncturists, hypnotists, herbalists, traditional healers or other related
disciplines;
(viii) vocational guidance, child guidance, marriage guidance, school therapy or
remedial education;
(ix) illness or injury arising from any wilful or deliberate self-inflicted act or act
inflicted with the consent of the injured party provided that it was in the
opinion of the Board, reasonably foreseeable that such illness or injury could arise from such wilful or deliberate act;
(x) illness or injury directly arising from the culpable negligence or unlawful act of a member or dependant;
(xi) treatment, including injections, for which a service is available free or at a nominal charge;
(xii) injury or illness resulting from participation in what is regarded by the Society as a hazardous sport;
(xiii) injury or illness resulting from participation in any sport or recreational pursuit with the object of monetary gain.
(h) Treatment incurred outside Zimbabwe shall, subject to these Rules, be paid for at the Society's scheduled rates.
(i) Whilst the Society is fully aware of the fact that medicine and dentistry is practiced on an individual basis and consequently there
are inevitably variances in the cost of treatment rendered by different practitioners. Where a practitioner's practice of medicine or
dentistry is persistently more expensive than that of his colleagues, the Board may, at its sole discretion, repudiate liability in
whole or in part for any expenses incurred by a member or dependant attending such practitioner.
Provided that the member and practitioner are given reasonable notice of the Board's decision to implement such measures.
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11. Submission of Claims
(a) A member wishing to avail himself of the benefits offered by the Society shall
submit, or cause to be submitted on his behalf, a claim in respect thereof in such
manner as the Board may from time to time prescribe.
(b) All relevant documents and accounts, whether paid or not, shall be attached to and
submitted with each claim.
(c) No claim shall be considered by the Society unless the provisions of these Rules
have been complied with.
(d) Any claim not received within three (3) months from the date on which the service
was rendered, or in respect of prescribed drugs within two (2) months from the
date on which the prescribed drug was dispensed, shall be disallowed by the Board
unless the member satisfies the Board that the failure to submit the claim or the
failure to cause the claim to be submitted on his behalf, was in no way due to the
member's inaction or negligence.
(e) In the event of the Society receiving a claim within the prescribed periods
mentioned in (d), and having to send the claim out to either the member or the
relevant provider of services for further information, then such claim shall be
returned to the Society within two (2) months from the date on which the claim
was dispatched from the Society. Any claim which is not returned to the Society
within such prescribed period, shall be disallowed by the Board unless the member
satisfies the Board that the failure to return the claim or the failure to cause the
claim to be returned on his behalf, was in no way due to the member's inaction or
negligence.
(f) Payments in respect of claims accepted by the Society shall be made direct to the member, provided however that the Board shall
have the power at its sole discretion to make payment to the person or institution rendering the service in respect of which the
claim is made.
12. Payment of Debts
If any payment is made in excess of a member's entitlement under these Rules or if, for any other reason whatsoever, a member
becomes indebted to the Society and should he fail to refund such excess payment or settle his indebtedness within a period of
thirty (30) days of notification thereof being sent to him, the Society shall, in addition to any other lawful remedies, have the right
to -
(i) deduct the overpayment or other debt from any amounts thereafter becoming due under these Rules in respect of any claim
accepted from that member; or
(ii) where applicable, request the member's employer to deduct the amounts due, either in full or by monthly instalments, from
the member's salary.
13. Financial Year
The Financial Year of the Society is from 1 January to 31 December.
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Head Office Harare
Cimas House
Cnr Jason Moyo Ave./Harare Street
PO Box 1243
Harare, Zimbabwe
Tel: +263 (0)4 777300-15
Fax: +263 (0)4 753567
Email: [email protected];
[email protected]
Cimas Bulawayo
Suite 4, Medical Centre
Cnr Josiah Tongogara St./8th Ave.
PO Box 5
Bulawayo, Zimbabwe
Tel: +263 (0)9 64873, +263 (0)9 72318
Toll Free: 0800 322 4 627 Cimas Gweru
23 Sixth Street
0800 4 318 - 20 PO Box 1402
Gweru, Zimbabwe
Tel: +263 (0)54 26178
Cimas Mutare
98 Second Street
PO Box 712 or 2560
Mutare, Zimbabwe
Tel: +263 (0)20 67703, +263 (0)20 67639
Fax: +263 (0)20 67795
Together we make a difference
www.cimas.co.zw
