Elite

Our ELITE option has been thoughtfully created with a clear vision to provide elite benefits that offer best-in-class cover, to ensure complete peace of mind knowing we have you covered. This option is perfectly suited for individuals who don’t compromise on cover. We don’t.

GAP BENEFIT

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 5 000 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.
  • You are also covered for 1 co-payment up to an amount of R 8 500 per policy per year, for the voluntary use of a hospital or day clinic outside your medical scheme’s designated network.

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 295
FamilyR 355
65+ *
SingleR 470
FamilyR 575

* 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.

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.

CANCER DIAGNOSIS BENEFIT

  • Our CANCER DIAGNOSIS BENEFIT, which ceases at age 65, provides a once-off payment of R 30 000 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 specific service providers’ accounts, leaving you liable to pay a portion of, or the full amount of the account.

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 internal prostheses, non-PMB day procedures, renal dialysis and MRI & CT scans but the device, procedure, treatment or scan costs more than the amount your medical scheme pays.
  • You are also covered when your medical scheme provides you with a MRI & CT scan benefit but applies a rand amount limit, known as a sub-limit or annual limit, from which you can claim every year. Once this rand amount limit is reached, you will be liable to pay all costs thereafter.

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, or the service providers’ accounts relating to your non-PMB day procedure or renal dialysis treatment, up to R 30 000 per event with a maximum of R 60 000 per person per year.
  • You will also be covered for a total number of 2 MRI or CT scans up to an amount of R 2 500 per scan per policy per year, when you
    become liable to settle a portion of, or the full amount of your service provider’s account.

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 10 000 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 and deserve, 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 10 000 per policy per year.

REHABILITATION OPTIMISER BENEFIT

WHY WE COVER YOU

Our REHABILITATION OPTIMISER BENEFIT helps to get your life back on course, when you need physical rehabilitative care and access to skilled therapists in the event of an unforeseen accident.

WHEN WE COVER YOU

  • You are covered when your medical scheme provides you with a rehabilitation benefit for accidental events, but applies a rand amount limit or a limit to the number of days you may be admitted, from which you can claim per year. Once these limits are reached, you will be liable to pay all treatment costs thereafter.

WHAT WE COVER YOU FOR

  • Our REHABILITATION OPTIMISER BENEFIT covers your rehabilitation treatment provided by on-site therapists as well as your stay at a registered sub-acute or step-down facility, when your medical scheme no longer does and is limited to R 10 000 per person per year.

PREVENTATIVE CARE BENEFIT

WHY WE COVER YOU

Our PREVENTATIVE CARE BENEFIT has been caringly put together to provide you the opportunity to undergo specific preventative screening tests when you are concerned about your health and wellbeing.

WHEN WE COVER YOU

  • You are covered when you undergo a Pap smear, prostate screening (PSA test) or a full blood count (FBC test) to help diagnose certain cancers.
  • We will refund the cost of your service provider’s consultation fee and the cost of your test when you become liable to pay out of your own pocket, or when your medical scheme pays the cost from your medical scheme savings account.

WHAT WE COVER YOU FOR

  • Our PREVENTATIVE CARE BENEFIT covers your consultation fees or the cost of the tests up to an amount of R 500 per policy per year.

ADDITIONAL BENEFITS

WHY WE COVER YOU

Our ADDITIONAL BENEFITS offer you and your loved ones the security of knowing that when you are faced with unexpected change resulting in financial difficulty, your cover will remain unchanged because we have you covered.

WHEN AND WHAT WE COVER YOU FOR

  • Our GAP POLICY PREMIUM WAIVER BENEFIT covers your Stratum Benefits policy premium for 12 months in the event of death, permanent disability or forced retrenchment of the Stratum Benefits policy premium payer.
  • Our MEDICAL SCHEME CONTRIBUTION WAIVER BENEFIT covers your medical scheme contribution for 6 months to a maximum of
    R 4 500 per month, in the event of death or permanent disability of the medical scheme contribution payer.
  • Our ACCIDENTAL DEATH BENEFIT provides a payment of R 25 000 in the event of the accidental death of the principal insured or spouse and R 5 000 for the accidental death of a dependant.
  • These benefits are not subject to the Overall Policy Limit (OPL).

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, where applicable.