Compact 200

  • Compact 200 Gap Cover

Our COMPACT 200 Gap Cover option has been conceptualised with medical scheme members in mind because when account shortfalls affect your financial well-being, we’ll absorb the impact. Complete peace of mind is offered by our comprehensive benefits that fill the gaps in your medical scheme cover. We cover you when your medical scheme does not pay your private healthcare fees in full, refund upfront
co-payment costs and lend a helping hand when you need oncology treatment.

GAP BENEFIT

WHY WE COVER YOU

Our COMPACT 200 GAP COVER option 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 200% 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

CO-PAYMENT BENEFIT

WHY WE COVER YOU

Our CO-PAYMENT BENEFIT provides you with the peace of mind that when your medical scheme requires you to pay upfront costs, we have you covered.

WHEN WE COVER YOU

  • You are covered when your medical scheme requires you to settle a fee, known as a co-payment, deductible or hospital admission fee, prior to undergoing certain in- and out-of-hospital medical procedures or specialised radiology scans.
  • We will refund the co-payment, deductible or hospital admission fee which is either settled by you or deducted from your medical scheme savings account.

WHAT WE COVER YOU FOR

  • Our CO-PAYMENT BENEFIT covers in- and out-of-hospital medical procedure related and specialised radiology scan co-payments, deductibles or hospital admission fees, represented as either a rand amount or a percentage and is limited to R 15 000 per policy per year.

GAP COVER FOR INDIVIDUALS WITH AN OVERALL POLICY LIMIT (OPL)
OF R 150 000 PER PERSON PER YEAR

ENTRY AGES MONTHLY PREMIUM
64 and younger
SingleR 182
64 and younger
FamilyR 212
65+ *
Single or FamilyR 353

* 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 GAP BENEFIT, CO-PAYMENT BENEFIT or SUB-LIMIT 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 total claim amount will be payable.

Where a claim under our GAP BENEFIT, CO-PAYMENT BENEFIT or SUB-LIMIT 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.

ONCOLOGY BENEFITS

WHY WE COVER YOU

Our ONCOLOGY BENEFITS alleviate the financial pressure that is not conducive to an environment of healing, by offering you superior and unique benefits for your necessary oncology treatment.

WHEN AND WHAT WE COVER YOU FOR

ONCOLOGY BENEFIT

  • You are covered when your medical scheme only pays a portion towards your approved oncology treatment such as radiotherapy, chemotherapy, basic and specialised radiology, pathology, specialist consultations, registered oncology facility fees, biological or specialised medication etc. The difference you are liable for may be referred to as a co-payment by certain medical schemes, or may reflect as a rand amount where your service provider charges a rate more than what your medical scheme pays.
  • Our ONCOLOGY BENEFIT covers you when your medical scheme only pays a portion towards your service providers’ accounts.

ONCOLOGY OPTIMISER BENEFIT

  • You are covered when your medical scheme provides you with an oncology benefit but applies a rand amount limit from which you can claim per year. Once this rand amount limit is reached, you will be liable to pay all treatment costs thereafter.
  • Our ONCOLOGY OPTIMISER BENEFIT covers your oncology treatment costs when your medical scheme no longer does and is limited to
    R 50 000 per person per year.

CANCER DIAGNOSIS BENEFIT

  • Our CANCER DIAGNOSIS BENEFIT, which ceases at age 65, provides a once-off payment of R 15 000 when you are diagnosed with cancer for the first time and the diagnosis aligns to specific qualifying criteria.
  • This benefit is not subject to the Overall Policy Limit (OPL).

SUB-LIMIT BENEFIT

WHY WE COVER YOU

Our SUB-LIMIT BENEFIT affords you the opportunity to ensure that your health and recovery remain a priority, when your medical scheme applies a rand amount limit to your internal prostheses benefit, leaving you liable to pay a portion of the cost.

WHEN WE COVER YOU

  • You are covered when your medical scheme provides you with a rand amount limit, known as a sub-limit or annual limit, from which you can claim for an internal prosthesis but the device costs more than the amount your medical scheme pays.

WHAT WE COVER YOU FOR

  • Our SUB-LIMIT BENEFIT provides cover when you become liable to settle a portion of your internal prosthesis provider’s account, up to
    R 15 000 per event with a maximum of R 30 000 per person per year.

CASUALTY BENEFIT

WHY WE COVER YOU

Our CASUALTY BENEFIT offers rich benefits to ensure that you not only receive the very best medical care, but also not having to worry about an unforeseen out of pocket expense for a casualty event.

WHEN WE COVER YOU

  • You are covered at a registered medical facility in the event of an accident, when immediate treatment is required for physical injury resulting from an external force outside your body due to impact with someone or something.
  • We will refund the cost of the casualty event to you when you become liable to pay out of your own pocket, or when your medical
    scheme pays the event from your medical scheme savings account.

WHAT WE COVER YOU FOR

Our CASUALTY BENEFIT covers the cost of your casualty event, including return visits for follow-up treatment that is required as a result of your initial casualty event, up to R 5 000 per policy per year, for accounts related to the following:

  • Doctor or specialist consultations
  • Basic and specialised radiology
  • Pathology
  • Consumable items such as surgical gloves, bandages and gauze
  • Medication provided as part of your casualty event at the registered medical facility
  • Upfront casualty co-payments or facility fees

TRAUMA COUNSELLING BENEFIT

WHY WE COVER YOU

Our TRAUMA COUNSELLING BENEFIT ensures you receive the support you need, when circumstances outside of your control alter the course of your life.

WHEN WE COVER YOU

  • You are covered when you have witnessed, or are directly affected by an act of physical violence or an accident resulting in serious bodily injury or death.
  • You are also covered when you are diagnosed with a dread disease, or are affected by a loved one’s diagnosis of a dread disease or death.
  • We will refund the cost of the registered counsellor’s, clinical psychologist’s or psychiatrist’s consultation fee when you become liable to pay out of your own pocket, or when your medical scheme pays the fees from your medical scheme savings account.

WHAT WE COVER YOU FOR

  • Our TRAUMA COUNSELLING BENEFIT covers your consultation fees up to R 5 000 per policy per year.

ADDITIONAL BENEFIT

ACCIDENTAL DEATH BENEFIT

WHY WE COVER YOU

Our ACCIDENTAL DEATH BENEFIT offers you and your loved ones the security of knowing that when you are faced with unexpected change resulting in financial difficulty, we have you covered.

WHEN AND WHAT WE COVER YOU FOR

  • Our ACCIDENTAL DEATH BENEFIT provides a payment of R 15 000 in the event of the accidental death of the principal insured or spouse and R 5 000 for the accidental death of a dependant.
  • This benefit is not subject to the Overall Policy Limit (OPL).