Whether you’re a single 18-year-old or vibey 66-year-old, this Gap Cover option gives you the edge against unexpected out-of-pocket medical expenses for doctors, specialists and casualty events. We’ve also added a premium waiver benefit to keep you on cover when it matters most.
WE COVER YOU
- As the only insured person on this policy.
- Whether you are the main member or dependant on your medical aid option.
- 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.
- 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% 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 year;
- Dental procedures related to accidental injury or cancer, limited to R 6 000 per year;
- Basic radiology;
- Specialised radiology limited to MRI, CT, PET scans and ultrasounds to R 2 000 per year;
- Consumable items such as surgical gloves and bandages.
- Medication administered or provided during your medical event.
- Prescribed Minimum Benefit (PMB) medical procedures
- 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;
- 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.
- 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 3 500 per year.
Gap Policy Premium Waiver Benefit (Not subject to the OPL)
- Your Gap Cover policy premium for a period of 12 months when the person paying your premium is forcibly retrenched, becomes totally and permanently disabled or passes away.
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.
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WAITING PERIODS, BENEFIT AND GENERAL EXCLUSIONS
YOUR GAP COVER POLICY WAITING PERIODS
From the first day your cover starts, waiting periods will apply before you are able to claim from specific policy benefits 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
- Line items on your healthcare providers’ accounts;
- paid in full from your hospital or risk benefit, or as a concession or ex-gratia payment.
- not partially paid from your hospital or risk benefit.
- partially paid or paid in full from your day-to-day benefit or medical savings account.
- while you are in your medical aid self-payment gap.
- for a private upfront fee that you must pay and cannot claim back from your medical aid.
- for specialised radiology except for MRI, CT, PET scans and ultrasounds.
- for out-patient consultation fees, except where the fee forms part of a medical procedure partially paid from your hospital or risk benefit.
- for consumable items not partially paid from your hospital or risk benefit.
- for medication not partially paid from your hospital or risk benefit, as well as prescription and take-home medication.
- for allied healthcare providers such as occupational and speech therapists, unless our benefit specifically makes provision for cover.
- for treatment dates that differ from the date of your claimable medical event.
- 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.
- 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.
- Hospital accounts including, but not limited to theatre and ward fees.
OUR CASUALTY BENEFIT DOES NOT COVER
- Healthcare providers’ accounts;
- for a casualty event not due to an accident, or not due to illness of your child under the age of 5.
- for a casualty event due to an accident, but medical treatment was not provided immediately.
- for medication not administered or provided during your casualty event or your related follow-up consultation, as well as prescription and take-home medication.
- for a return visit for follow-up treatment not related to an accident.
- for external medical items not received during your initial casualty event.
- 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.
- 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.
- for a casualty event where medical treatment due to illness was provided to your child aged 5 and older.
- paid in full from your risk benefit.
OUR GAP POLICY PREMIUM WAIVER BENEFIT DOES NOT COVER
- where the person paying your premium has not been forcibly retrenched, has not become totally and permanently disabled or has not passed away.
- for which a claim is received for forced retrenchment, total and permanent disability or death of a person not noted as the premium payer.
- where a new premium payer is appointed 3 months before to the claimable event, except where total and permanent disability or death is due to an accident.
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:
- Events you want to claim for, but you are not an insured person at the time of the event.
- Events that occur during your policy waiting period(s), unless you are claiming for an accidental event.
- Events where a benefit limit or a policy limit has been reached.
- Events where your policy does not provide the appropriate benefit for you to claim from.
- Events where you did not obtain pre-authorisation from your medical aid, or where you did not follow your medical aid’s rules.
- 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.
- Medical aid exclusions where no underlying cover exists, unless a benefit specifically makes provision for cover.
- Maxillo-facial surgery and related medical conditions and/or procedures, unless your claim is related to accidental injury or cancer.
- External prostheses such as artificial limbs, or external medical items such as wheelchairs and crutches, unless a benefit specifically makes provision for cover.
- Robotic surgery, unless your claim is related to a medical expense shortfall for which a benefit specifically makes provision for cover.
- The use of specialised mechanical or computerised
- Artificial insemination, infertility treatment, procedures or contraceptives, except for tubal ligation and vasectomies.
- Obesity and bariatric surgery.
- Non-medically necessary reconstructive cosmetic surgery.
- 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.
- 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.
- Depression, insanity, emotional or mental illness or any stress-related conditions.
- Costs associated with supporting medical reports that assist in the finalisation of your claim.
- Routine physical, diagnostic procedures or examinations where there is no objective indication of impairment in your health.
- Expenses incurred for transport charges or for healthcare services that you receive during transportation in an emergency vehicle, vessel or aircraft.
- Riots, wars, political acts, public disorder, terrorism, civil commotions, labour disturbances, strikes, lock-out, or any attempted such acts.
- 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.
- Attempted suicide, intentional self-injury and deliberate exposure to exceptional danger except when you attempt to save a human life.
- Events where the use of drugs or alcohol is involved.
- Active military, police and police reservist activities whilst on active duty.
- 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.
- Events where the actual damage is covered by legislation, such as contractual liability and consequential loss.
- Discounts directly negotiated with your healthcare provider where full reimbursement of the claim will result in enrichment.
- Non-disclosure of material information that is likely to affect the assessment or acceptance of risk.
- Dual insurance where cover is provided by more than one gap cover policy through different insurers, or the same insurer.