Access Optimiser

  • Access Optimiser Gap Cover

Our ACCESS OPTIMISER Gap Cover option has been skilfully designed to provide you with the necessary cover for a medical procedure that is not claimable from your medical scheme because the procedure is listed as a specific exclusion.

ACCESS OPTIMISER BENEFIT

WHY WE COVER YOU

Our ACCESS OPTIMISER GAP COVER option leaves you feeling comforted and confident knowing that when your medical scheme does not cover specific medical procedures that are excluded but necessary for your wellbeing, your gap cover provider will.

WHEN WE COVER YOU

  • You are covered when your medical scheme excludes a medical procedure that forms part of a specific list of exclusions, over and above the general exclusions applicable to your medical scheme option, leaving you liable to pay all hospital and related service providers’ accounts in full.

WHAT WE COVER YOU FOR

  • Our ACCESS OPTIMISER BENEFIT provides cover for your hospital and service providers’ accounts up to the rand amount limit for the below listed medical procedures:

IMPORTANT TO KNOW

  • Our ACCESS OPTIMISER BENEFIT grants you the freedom of choice when your doctor informs you that you require a medically necessary procedure but your medical scheme excludes the procedure because it is listed as a specific exclusion. We do not decide which service providers you may use but allow you to inform us of whom you trust.
  • The rand amount limits our ACCESS OPTIMISER BENEFIT provides for the medical procedure you require, will be used to cover all service providers’ costs. You will be liable for the difference where your chosen service providers charge a rate that exceeds the rand amount limit we provide. You will be required to provide us with a quotation from each service provider, whom we will contact on your behalf and provide a guarantee of payment where applicable. Payment will be made directly to the service providers once your claim has been approved.
MEDICAL PROCEDURE NOT
COVERED BY YOUR MEDICAL SCHEME
ACCESS OPTIMISER
BENEFIT
WILL COVER
Arthroscopic surgery  R 50 000
Back or neck surgery  R 50 000
Bunion surgery  R 14 000
Cochlear implant, auditory brain implant and internal nerve stimulator surgery including the device and processor  R 80 000
Dental procedures for impacted teeth for child dependants under 18 years of age  R 14 000
Dental procedures for reconstructive plastic surgery due to an accident  R 80 000
Functional nasal surgery  R 23 000
Joint replacement surgery  R 50 000
Knee or shoulder surgery  R 25 000
Oesophageal reflux and hiatus hernia surgery  R 55 000
Varicose veins surgery  R 20 000

GAP COVER FOR INDIVIDUALS WITH AN OVERALL POLICY LIMIT (OPL)
OF R 100 000 PER POLICY PER YEAR OR WHEN ADDING OUR GAP BENEFIT INCREASES TO R 150 000 PER POLICY PER YEAR

ENTRY AGES MONTHLY PREMIUM
64 and younger
Single or FamilyR 237
Add Gap BenefitR 66
65+ *
Single or FamilyR 288
Add Gap BenefitR 116

* Limited to two insured individuals per policy

WE COVER
INDIVIDUALS 64 AND YOUNGER
  • We cover you and your spouse on one policy, even if you belong to different medical schemes or medical scheme options, including all dependants registered on your or your spouse’s medical scheme option.
INDIVIDUALS 65 AND OLDER
  • We cover you and your spouse on one policy, even if you belong to different medical schemes or medical scheme options, or you and one other dependant registered on your medical scheme option.
  • Where either one, or both individuals are 65 and older the 65+ premium will apply, limited to two insured individuals per policy.

Where a claim under our ACCESS OPTIMISER BENEFIT is received for a condition, procedure, surgery, treatment or an investigation and any related accounts in respect of Arthroscopic surgery, Back or neck surgery, Bunion surgery, Cochlear implant, auditory brain implant and internal nerve stimulator surgery including the device and processor, Dental procedures for impacted teeth for child dependants under 18 years of age, Dental procedures for reconstructive plastic surgery due to an accident, Functional nasal surgery, Joint replacement surgery, Knee or shoulder surgery, Oesophageal reflux and hiatus hernia surgery and Varicose veins surgery within the first 10 months of cover, and is not deemed as pre-existing or accidental, 20% of the medical expense shortfall amount will be payable.

ADD OUR GAP BENEFIT

Our ACCESS OPTIMISER BENEFIT covers medically necessary procedures that your medical scheme won’t.

When our GAP BENEFIT is added at an additional monthly premium as per the premium breakdown, the shortfall that exists between what your medical scheme pays and the fee charged for private healthcare for medical procedures that do not form part of your medical scheme’s list of specific exclusions, will be covered.

WHY WE COVER YOU

Our GAP BENEFIT leaves you feeling assured that when an in- or out-of-hospital medical procedure is necessary and your service provider, such as your doctor or specialist, charges a rate more than what your medical scheme pays, the unexpected difference you are liable for won’t leave you out of pocket.

WHEN WE COVER YOU

  • You are covered when your service providers charge a rate more than what your medical scheme pays for medical procedures performed in hospital, doctors’ and specialists’ private rooms, day clinics and other registered facilities, provided your service providers’ accounts are paid from your medical scheme hospital benefit, also known as a risk or major medical benefit, and not from your medical scheme savings account or day-to-day benefit.
  • You are covered for Prescribed Minimum Benefit (PMB) medical procedures.

WHAT WE COVER YOU FOR

Our GAP BENEFIT provides an additional 500% cover, when you become liable for the difference between what your service providers charge, and what your medical scheme pays from your medical scheme hospital benefit for account shortfalls related to the following:

  • Doctors and specialists
  • Dentistry and related procedures limited to R 3 000 per policy per year
  • Basic radiology
  • Specialised radiology limited to MRI, CT and PET scans up to
    R 2 000 per policy per year
  • Pathology
  • Physiotherapy
  • Consumable items such as surgical gloves, bandages and gauze
  • Medication provided as part of your in- or out-of-hospital event

ADDITIONAL BENEFIT

ACCIDENTAL DEATH BENEFIT

WHY WE COVER YOU

Our ACCIDENTAL DEATH BENEFIT offers you and your spouse the security of knowing that when you are faced with unexpected change due to the loss of a loved one, we have you covered.

WHEN AND WHAT WE COVER YOU FOR

  • Our ACCIDENTAL DEATH BENEFIT provides a payment of R 5 000 in the event of the accidental death of the principal insured or spouse.
  • This benefit is not subject to the Overall Policy Limit (OPL).

Where a claim under our GAP BENEFIT is received for a condition, procedure, surgery, treatment or an investigation and any related accounts in respect of Adenoidectomy, Tonsillectomy, Myringotomy/ Grommets, Cardiovascular procedures, Cataract removal, Dentistry, Hysterectomy (unless due to cancer diagnosis), Hernia repair, Joint replacement, MRI, CT and PET scans, Nasal and sinus surgery, Pregnancy and childbirth, Spinal procedures and Scopes within the first 10 months of cover, and is not deemed as pre-existing or accidental, 20% of the medical expense shortfall amount will be payable.