If you belong to a medical aid option that applies a rand amount limit to the cost of hospitalisation and all related healthcare providers’ accounts, then this Gap Cover option is for you.
We optimise cover by increasing your medical aid option’s overall annual hospital limit so that you don’t have to worry about future hospital admissions and medical bills. Leave that up to us!
We’ve also added funeral cover to help your loved ones in a time of need.
- 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.
HOSPITAL OPTIMISER BENEFIT
- The cost of your stay in hospital or a day clinic, as well as the cost of all your related healthcare providers’ accounts when you need to undergo a medical procedure, surgery, treatment or an investigation that you cannot claim from your medical aid because your medical aid option’s overall annual hospital limit has been reached.
- Your medical event according to your medical aid’s rules and the rate your medical aid pays.
EXAMPLE OF HOW OUR HOSPITAL OPTIMISER BENEFIT ENSURES YOUR MEDICAL EVENT IS COVERED
|THE OVERALL ANNUAL HOSPITAL LIMIT (OAL) APPLICABLE TO YOUR MEDICAL AID OPTION||+||THE AMOUNT OUR HOSPITAL OPTIMISER BENEFIT PROVIDES||=||THE TOTAL BENEFIT AMOUNT YOU WILL BE COVERED FOR WHEN ADDING OUR HOSPITAL OPTIMISER BENEFIT|
|R 150 000||R 157 000||R 307 000|
|R 300 000||R 457 000|
|R 800 000||R 957 000|
|R 1 000 000||R 1 157 000|
FUNERAL CARE BENEFIT
- You, the Principal Insured person, in the event of death to a benefit amount of R 10 000.
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 HOSPITAL OPTIMISER BENEFIT DOES NOT COVER
- Healthcare providers’ accounts;
- partially paid or paid in full from your hospital or risk benefit, or as a concession or ex-gratia
- partially paid or paid in full from your day-to-day benefit or medical savings account, except when our benefit applies because your overall annual hospital limit has been reached and your medical aid pays your medical event from your day-to-day benefit, or from funds available in your medical savings account.
- 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 medical event.
- where your medical aid provides a sub-limit or annual limit from which you can claim, but the sub-limit or annual limit has been reached at the time of your medical event.
- while you are in your medical aid self-payment gap.
- for treatment dates that differ from the date of your claimable medical event.
- for a private upfront fee that you must pay and cannot claim back from your medical aid.
- for out-patient consultation fees.
- for prescription and take-home medication.
- for allied healthcare providers such as occupational and speech therapists, unless our benefit specifically makes provision for cover.
- where you have not followed your medical aid’s rules, or where a facility or healthcare provider was used that does not form part of your medical aid’s preferred provider network.
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, where applicable.
- 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
- Dental implants, orthodontic, prosthodontic or cosmetic dentistry.
- External prostheses such as artificial limbs, or external medical items such as wheelchairs and crutches.
- Robotic surgery, specialised mechanical or computerised items and equipment.
- 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 or admission to a step-down facility such as a frail care centre, 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.