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Gap Cover & Health Insurance for Real People

GAP COVER

BASE

Life can be unpredictable, and so can your health.

This Gap Cover option is based on real benefits that offer real cover when it matters most, because when you become liable to pay doctors’ and specialists’ bills that your medical aid doesn’t cover in full, we’ve got the basics covered.

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.
  • Each insured person to an Overall Policy Limit (OPL) of R 157 000 per person 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
BASE SINGLE R 199,00
BASE FAMILY R 230,00
BASE 65+ R 387,00

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 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 R3 000 per policy per year;
    • Dental procedures related to accidental injury or cancer, limited to R6 000 per policy per year;
    • Basic radiology;
    • Specialised radiology limited to MRI, CT, PET scans and ultrasounds to R2 000 per policy per year;
    • Pathology;
    • Physiotherapy;
    • Consumable items such as surgical gloves and bandages;
    • Medication administered or provided during your medical event.
    • Prescribed Minimum Benefit (PMB) medical procedures

CASUALTY BENEFIT

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 R7 000 per policy per year.

TRAUMA COUNSELLING BENEFIT

WE COVER
  • The cost of your trauma counselling consultation fees when you:
    • have witnessed, or are directly affected by an act of physical violence or an accident;
    • have received word of a loved one’s, or your own diagnosis of a dread disease; or
    • mourn the death of a loved one.
  • You will be refunded for the cost of your registered counsellor’s, clinical psychologist’s or psychiatrist’s consultation fees 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 R6 000 per policy per year.

ONCOLOGY CARE BENEFIT

CANCER DIAGNOSIS BENEFIT (Not subject to the OPL)

WE COVER

  • A once-off benefit amount of R5 000 when you are diagnosed with cancer for the very first time before you reach the age of 65, subject to specific qualifying criteria as explained under our benefit exclusions.

 

ADDITIONAL BENEFIT

ACCIDENTAL DISABILITY AND DEATH BENEFIT (Not subject to the OPL)

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 R6 000.

TRAVEL INSURANCE

Travelling abroad?

Whenever, wherever …….

From the moment you need medical assistance to the time your healthcare providers’ accounts are paid, your international travel insurance provider will be with you all the way.

Limited to 1 event per policy per year.

LIFESTYLE BENEFIT

(Launching 1 December 2018)

STRATUM FUEL REWARDS

Get more bang for your buck!

Fill up with diesel at any Shell service station and get rewarded with 22 cents cash back per litre.

A litre really goes a long way!

OUR 20% BENEFIT RULE

Should you claim from our GAP 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:

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 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.

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 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 payment.
    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 savingsaccount.
    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 yourmedical 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 medicalprocedure 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.

 

OUR TRAUMA COUNSELLING BENEFIT DOES NOT COVER
  1. Healthcare providers’ accounts;
    1. if you have not witnessed or are not directly affected by an act of physical violence or an accident.
    2. if you are not affected by a loved one’s diagnosis of a dread disease or death, or by your own diagnosis of a dread disease.
    3. paid in full from your risk benefit.
    4. if your healthcare provider is not registered with a recognised South African regulatory body.

 

ONCOLOGY CARE BENEFIT

OUR CANCER DIAGNOSIS BENEFIT DOES NOT COVER
  1. A cancer diagnosis;
    1. that is not the first diagnosis made in your lifetime.
    2. made before the first day your cover starts or during a GENERAL WAITING PERIOD.
    3. for cancers of the skin, unless the cancer diagnosis is for cancerous moles that have invaded surrounding or underlying tissue.
    4. where cancerous cells have not invaded surrounding or underlying tissue.
    5. for Stage 1 breast or prostate cancer.
    6. made after you have reached the age of 65.

 

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), unless you are claiming for an accidental event.
  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 items.
  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.