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Gap Cover & Health Insurance for Real People

GAP COVER

ACCESS OPTIMISER

Living a happier, healthier life is key and now you have access to help you on your way!

Medical aids exclude specific medical procedures and events as part of a list of general exclusions. Some medical aids exclude additional procedures over and above the general exclusions. Does yours?

This Gap Cover option allows you to start planning for that much needed medical procedure or treatment that you cannot claim from your medical aid.

Living a happier, healthier life is key and now you have access to help you on your way!

WE COVER
  • You and your spouse on one policy, even if you belong to different medical aids or medical aid options, including all dependants registered on your or your spouse’s medical aid option.
  • You and your dependants to an Overall Policy Limit (OPL) of R 100 000 per policy per year or when adding our Gap benefit to R 157 000 per person per policy per year.

This is not a medical aid and the cover is not the same as that of a medical aid. This policy is not a substitute for medical aid membership.

MONTHLY PREMIUMS

ENTRY AGES MONTHLY PREMIUM
64 or younger R 252,00

Add our 200% Gap Benefit

R 279,00

Add our 500% Gap Benefit

R 322,00

65 or older R 311,00

Add our 200% Gap Benefit

R 358,00

Add our 500% Gap Benefit

R 436,00

ACCESS OPTIMISER BENEFIT

WE COVER
  • You when your medical aid does not provide cover for a medical procedure or treatment that forms part of a specific list of exclusions, in addition to the procedures and treatments that form part of your medical aid option’s general exclusions.
  • The cost of the hospital or day clinic, and all related healthcare providers’ accounts when you need one of the below listed medical procedures or treatments that you cannot claim from your medical aid, limited to the rand amount as indicated.
MEDICAL PROCEDURE NOT COVERED BY YOUR MEDICAL AID OUR ACCESS OPTIMISER BENEFIT COVERS
Arthroscopic surgery R 50 000
Back or neck treatment or surgery R 50 000
Bunion surgery R 14 000
Cochlear implant, auditory brain implant and internal nerve stimulator surgery (including the procedure, device, processor and hearing aids)

R 80 000

 

Dental procedures for impacted teeth for children younger than 18 R 14 000
Dental procedures for reconstructive surgery required due to an accidental event R 80 000
Functional nasal surgery R 23 000
Joint replacement surgery R 50 000
Knee or shoulder surgery R 25 000
Non-cancerous breast conditions R 20 000
Oesophageal reflux and hiatus hernia surgery R 55 000
Removal of varicose veins R 20 000
Skin disorders (including benign growths and lipomas) R 20 000
YOUR NEXT STEP
  • When your doctor informs you that you need a medical procedure or treatment that forms part of the list of procedures or treatments that we cover, you will be required to obtain cost estimates from your preferred hospital or day clinic and all related healthcare providers.
  • We will issue a guarantee of payment as an undertaking to pay your service and healthcare providers directly once your claim is approved.

OUR 20% BENEFIT RULE

OUR 10 MONTH BENEFIT RULE
Should you claim from our ACCESS OPTIMISER BENEFIT after the General Waiting Period but within the first 10 months of cover for the below listed medical events, your related healthcare providers’ accounts will be covered at 20% of the approved medical expense shortfall amount:

Arthroscopic surgery, Back or neck surgery, Bunion surgery, Cochlear implant, auditory brain implant and internal nerve stimulator surgery (including the procedure, device, processor and hearing aids), Dental procedures for impacted teeth for children younger than 18, Functional nasal surgery, Joint replacement surgery, Knee or shoulder surgery, Noncancerous breast conditions, Oesophageal reflux and hiatus hernia surgery, Removal of varicose veins and Skin disorders (including benign growths and lipomas).

If your medical event is due to a pre-existing medical condition, your claim will be subject to the Pre-Existing Condition Waiting Period applicable to your policy. If this waiting period does not apply your claim will be covered at 20% as specified above.

Claims for accidental events that occur after your cover start date will be covered in full from the first day of cover.

ADD OUR 200% OR 500% GAP BENEFIT

Our ACCESS OPTIMISER BENEFIT covers specific medical procedures and treatments that your medical aid excludes from cover.

Our GAP BENEFIT covers the difference in cost when your healthcare providers’ charge more than the rate your medical aid pays for medical procedures that are not excluded from cover.

When our 200% GAP BENEFIT is added at an additional monthly premium, your policy automatically upgrades to our ACCESS PLUS 200 OPTION or when adding our 500% GAP BENEFIT your policy upgrades to our ACCESS PLUS 500 OPTION.

GAP BENEFIT

WE COVER
  • The gap that exists between what your healthcare providers charge and the rate your medical aid pays for medical procedures performed in hospital, a day clinic or your doctor’s or specialist’s private room when a portion of your healthcare providers’ accounts are paid from your hospital or risk benefit, and not from your day-to-day benefit or medical savings account.
  • Our GAP BENEFIT provides 200% or 500% cover, over and above the rate your medical aid pays for:
    • Medical procedures performed by your doctors and specialists;
    • Dental related procedures limited to R 3 000 per policy per year;
    • Dental procedures related to accidental injury or cancer, limited to R 6 000 per policy per year;
    • Basic radiology;
    • Specialised radiology limited to MRI, CT, PET scans and ultrasounds to R 2 000 per policy per year;
    • Pathology;
    • Physiotherapy;
    • Consumable items such as surgical gloves and bandages.
    • Medication administered or provided during your medical event.

OUR 20% BENEFIT RULE

Should you claim from our Gap Benefit in the first 10 months of cover, but after the General Waiting Period applicable to your policy for the below listed medical events, your related healthcare providers’ accounts will be covered at 20% of the approved medical expense shortfall amount:

Adenoidectomy, Tonsillectomy, Myringotomy/Grommets, Cardiovascular procedures, Cataract removal, Dentistry, Hernia repairs, Hysterectomy (if required due to cancer that is diagnosed after the General Waiting Period applicable to your policy, your claim will be covered in full), Joint replacements, MRI, CT and PET scans, Nasal and sinus surgery, Pregnancy and childbirth, Spinal procedures and Scopes.

If your medical event is due to a pre-existing medical condition, your claim will be subject to the Pre-Existing Condition Waiting Period applicable to your policy. If such a waiting period does not apply, your claim will be covered at 20% as specified above.

Claims for accidental events that occur after your cover start date, will be covered in full from the first day of cover.

CASUALTY BENEFIT

This benefit is automatically included when you belong to our ACCESS PLUS OPTIONS.

WE COVER
  • A casualty event at any registered medical facility when you require immediate medical treatment due to an accident.
  • Your healthcare providers’ accounts related to:
    • Doctors’ and specialists’ consultations;
    • Basic and specialised radiology;
    • Pathology;
    • Consumable items such as surgical gloves and bandages.
    • Medication administered or provided during your casualty event;
    • External medical items required as a result of your casualty event provided at the registered medical facility, such as a neck brace;
    • Return visits to the registered medical facility, when follow-up treatment is required as a result of your initial casualty event related to an accident; and
    • Upfront casualty co-payments or facility fees.
  • Your child under the age of 5, when they become ill and need after-hours medical treatment at a registered casualty facility.
  • You will be refunded for the cost of your casualty event when you become liable to pay your healthcare providers’ accounts out of your own pocket, or when your medical aid pays your healthcare providers’ accounts from your medical savings account, limited to R 1 000 per policy per year.

ADDITIONAL BENEFIT

This benefit is automatically included when you belong to our ACCESS PLUS OPTIONS.

WE COVER

  • You and your spouse in the event of your total and permanent disability or death due to an accident, limited to 1 event per person per year to a benefit amount of R 5 000.

LIFESTYLE BENEFIT

(Launching 1 December 2018)

STRATUM FUEL REWARDS

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WAITING PERIODS, BENEFIT AND GENERAL EXCLUSIONS

YOUR GAP COVER POLICY WAITING PERIODS

Waiting periods apply from each insured person’s cover start date before specific policy benefits can be claimed from, unless otherwise specified in your policy documentation.

3 MONTH GENERAL WAITING PERIOD

During this period, cover does not apply unless you are claiming for an accidental event that occurs after your cover start date.

12 MONTH PRE-EXISTING CONDITION WAITING PERIOD

During this period, cover does not apply for an investigation, treatment, procedure or surgery relating to any illness or condition that you have been diagnosed with and/or received advice or treatment for 12 months before your cover start date.

GAP COVER BENEFIT EXCLUSIONS

OUR ACCESS OPTIMISER BENEFIT DOES NOT COVER
  1. Healthcare providers’ accounts;
    1. partially paid or paid in full from your hospital, risk, day-to-day benefit or medical savings account, or as a concession or ex-gratia
    2. partially paid or paid in full from a sub-limit or annual limit where you become liable to pay a portion of, or the full amount of your healthcare providers’ accounts.
    3. where your medical aid provides a sub-limit or annual limit from which you can claim for your medical procedure, but the sub-limit or annual limit has been reached at the time of your medical event.
    4. while you are in your medical aid self-payment gap.
    5. for medical procedures and treatment excluded from medical aid cover, but do not form part of the list of medical procedures and treatment that we cover.
    6. related to Arthroscopic surgery, Back and neck treatment or surgery, Bunion surgery, Cochlear implant, auditory brain implant and internal nerve stimulator surgery (including the procedure, device, processor and hearing aids), Dental procedures for impacted teeth for children younger than 18, Functional nasal surgery, Joint replacement surgery, Knee or shoulder surgery, Non-cancerous breast conditions, Oesophageal reflux and hiatus hernia surgery, Removal of varicose veins or Skin disorders (including benign growths and lipomas) at more than 20% of the approved medical expense shortfall amount if claimed within the first 10 months of cover.

 

OUR GAP BENEFIT DOES NOT COVER
  1. Line items on your healthcare providers’ accounts;
    1. paid in full from your hospital or risk benefit, or as a concession or ex-gratia
    2. not partially paid from your hospital or risk benefit.
    3. partially paid or paid in full from your day-to-day benefit or medical savings account.
    4. while you are in your medical aid self-payment gap.
    5. for a private upfront fee that you must pay and cannot claim back from your medical aid.
    6. for specialised radiology except for MRI, CT, PET scans and ultrasounds.
    7. for out-patient consultation fees, except where the fee forms part of a medical procedure partially paid from your hospital or risk benefit.
    8. for consumable items not partially paid from your hospital or risk benefit.
    9. for medication not partially paid from your hospital or risk benefit, as well as prescription and take-home medication.
    10. for allied healthcare providers such as occupational and speech therapists, unless our benefit specifically makes provision for cover.
    11. for treatment dates that differ from the date of your claimable medical event.
    12. related to Adenoidectomy, Tonsillectomy, Myringotomy/Grommets, Cardiovascular procedures, Cataract removal, Dentistry, Hysterectomy, Hernia repair, Joint replacement, MRI, CT and PET scans, Nasal and sinus surgery, Pregnancy and childbirth, Spinal procedures or Scopes at more than 20% of the approved medical expense shortfall amount if claimed within the first 10 months of cover.
  2. Medical procedures subject to a rand amount limit, where you become liable to pay a portion of, or the full amount of your medical procedure because the benefit limit does not cover the full amount of your medical procedure, or where the benefit limit has been reached.
  3. Hospital accounts including, but not limited to theatre and ward fees.

 

OUR CASUALTY BENEFIT DOES NOT COVER
  1. Healthcare providers’ accounts;
    1. for a casualty event not due to an accident, or not due to illness of your child under the age of 5.
    2. for a casualty event due to an accident, but medical treatment was not provided immediately.
    3. for medication not administered or provided during your casualty event or your related follow-up consultation, as well as prescription and take-home medication.
    4. for a return visit for follow-up treatment not related to an accident.
    5. for external medical items not received during your initial casualty event.
    6. for a casualty event where treatment due to illness was provided to your child under the age of 5 at a medical facility other than a registered casualty facility.
    7. for a casualty event where treatment due to illness was provided to your child under the age of 5 at a registered casualty facility, but medical treatment was not provided after-hours. After-hours is Mondays to Fridays between 18:00pm and 07:00am and Saturdays, Sundays and public holidays.
    8. for a casualty event where medical treatment due to illness was provided to your child aged 5 and older.
    9. paid in full from your risk benefit.

 

ADDITIONAL BENEFIT

OUR ACCIDENTAL DISABILITY AND DEATH BENEFIT DOES NOT COVER
  1. Events;
    1. where total and permanent disability or death is not due to an accident.
    2. that exceed one claimable event per qualifying person in a benefit year.

 

GENERAL EXCLUSIONS APPLICABLE TO YOUR GAP COVER POLICY

We do not cover service or healthcare providers’ accounts for related medical procedures and/or treatment, nor hospitalisation, illness, disease, loss, damage, death, bodily injury or liability for:

  1. Events you want to claim for, but you are not an insured person at the time of the event.
  2. Events that occur during your policy waiting period(s).
  3. Events where a benefit limit or a policy limit has been reached.
  4. Events where your policy does not provide the appropriate benefit for you to claim from.
  5. Events where you did not obtain pre-authorisation from your medical aid, or where you did not follow your medical aid’s rules.
  6. Events where the hospital, day clinic, registered medical facility or healthcare provider used does not form part of your medical aid’s preferred provider network.
  7. Medical aid exclusions where no underlying cover exists, unless a benefit specifically makes provision for cover.
  8. Maxillo-facial surgery and related medical conditions and/or procedures, unless your claim is related to accidental injury or cancer.
  9. External prostheses such as artificial limbs, or external medical items such as wheelchairs and crutches, unless a benefit specifically makes provision for cover.
  10. Robotic surgery, unless your claim is related to a medical expense shortfall for which a benefit specifically makes provision for cover.
  11. The use of specialised mechanical or computerised
  12. Artificial insemination, infertility treatment, procedures or contraceptives, except for tubal ligation and vasectomies.
  13. Obesity and bariatric surgery.
  14. Non-medically necessary reconstructive cosmetic surgery.
  15. Breast reconstruction performed as a second or subsequent medical procedure, and/or the insertion or removal of a breast implant performed as a second or subsequent medical procedure.
  16. Home nursing, admission to a step-down or sub-acute facility such as a frail care centre or a rehabilitation facility, unless a benefit specifically makes provision for cover.
  17. Depression, insanity, emotional or mental illness or any stress-related conditions.
  18. Costs associated with supporting medical reports that assist in the finalisation of your claim.
  19. Routine physical, diagnostic procedures or examinations where there is no objective indication of impairment in your health.
  20. Expenses incurred for transport charges or for healthcare services that you receive during transportation in an emergency vehicle, vessel or aircraft.
  21. Riots, wars, political acts, public disorder, terrorism, civil commotions, labour disturbances, strikes, lock-out, or any attempted such acts.
  22. A deliberate criminal or fraudulent act, or any illegal activity conducted by you or a member of your household which directly or indirectly results in loss, damage or injury.
  23. Attempted suicide, intentional self-injury and deliberate exposure to exceptional danger except when you attempt to save a human life.
  24. Events where the use of drugs or alcohol is involved.
  25. Active military, police and police reservist activities whilst on active duty.
  26. Nuclear weapons material, ionising radiations or contamination by radioactivity from any nuclear fuel, nuclear waste or from the combustion of nuclear fuel that includes any self-sustaining process of nuclear fission.
  27. Events where the actual damage is covered by legislation, such as contractual liability and consequential loss.
  28. Discounts directly negotiated with your healthcare provider where full reimbursement of the claim will result in enrichment.
  29. Non-disclosure of material information that is likely to affect the assessment or acceptance of risk.
  30. Dual insurance where cover is provided by more than one gap cover policy through different insurers, or the same insurer.