BASE 

It’s our foundation option that covers the most frequent medical expense shortfalls that you’re most likely to experience on doctors’ and specialists’ private fees.

 

MONTHLY PREMIUM

If you’re an individual aged 65 or older, we’ll cover you under the 65+ individual option. If you apply for cover as a family, and either you or one of your dependants is 65 years or older, you and your family will be covered under the 65+ family option.

Joining as a family? One Gap Cover policy covers you, your spouse and all the dependants registered on both your and your spouse’s medical aid plan.

KEY BENEFITS SUBJECT TO AN OVERALL POLICY LIMIT (OPL)

An OPL of R 173 000 per person per year applies to the following benefits. This means that all approved claim amounts will get deducted off the OPL.

BASE 

It’s our foundation option that covers the most frequent medical expense shortfalls that you’re most likely to experience on doctors’ and specialists’ private fees.

 

MONTHLY PREMIUM

If you’re an individual aged 65 or older, we’ll cover you under the 65+ individual option. If you apply for cover as a family, and either you or one of your dependants is 65 years or older, you and your family will be covered under the 65+ family option.

Joining as a family? One Gap Cover policy covers you, your spouse and all the dependants registered on both your and your spouse’s medical aid plan.

KEY BENEFITS SUBJECT TO AN OVERALL POLICY LIMIT (OPL)

An OPL of R 173 000 per person per year applies to the following benefits. This means that all approved claim amounts will get deducted off the OPL.

GAP COVER

Going into hospital to have your appendix removed, or having a biopsy done in the doctor’s rooms?

Gap Cover kicks in when your doctor or specialist charges more than the amount your medical aid pays for in- and out-of-hospital medical procedures, as long as it’s paid from a hospital or risk benefit.

We add an additional 500% cover on top of what your medical aid plan gives to cover shortfalls for:

  • medical procedures performed by your doctor and specialist;
  • basic radiology, like black and white x-rays;
  • specialised radiology, like MRI and CT scans;
  • consumable items, like surgical gloves;
  • dental procedures, like wisdom teeth extractions, limited to R 6 000 per policy per year;
  • dental procedures due to accidents or cancer treatment, limited to R 8 000 per policy per year;
  • medication administered during your medical event;
  • pathology;
  • physiotherapy; and
  • Prescribed Minimum Benefit (PMB) medical

 Don’t forget… your medical aid must make payment from a hospital or risk benefit, and not from a day-to-day benefit or your medical savings account.

CASUALTY COVER

ACCIDENT COVER
For the whole family

For immediate medical treatment due to an accident you can go to your nearest medical facility.

ACCIDENTS are unexpected incidents that cause physical injury due to physical impact with someone or something.
IMMEDIATE means within 24-hours from the time of the incident.

What do we cover? Everything related to your casualty event, like:

  • co-payments and facility fees;
  • doctors’ consultation fees;
  • basic radiology, specialised radiology and pathology;
  • medication administered during your casualty event; and
  • external medical items that’s given to you at the medical facility, like a neck brace.

Need a follow-up visit to a medical facility after an accidental event to have stitches or a cast removed? We’ll refund that too.

ILLNESS COVER
Only for children younger than 8 years of age

If your child who’s younger than 8 gets sick after-hours, we’ll cover the cost of a visit to a casualty facility and all the healthcare providers’ accounts related to the visit.

WHEN IS AFTER-HOURS? Mondays to Fridays between 18:00pm and 07:00am and all-day Saturdays, Sundays and public holidays.

We’ll refund the amount that you pay from your own pocket or that your medical aid pays from a day-to-day benefit or your medical savings account.
Casualty Cover is limited to R 7 000 per policy per year.

TRAUMA COUNSELLING COVER

Sometimes you just need to talk to someone about it. If you’ve:

  • witnessed, or are directly affected by an act of physical violence or an accident;
  • received news of a loved one’s, or of your own diagnosis of a critical illness; or
  • mourn the death of a loved one,

we’ll refund the registered counsellor’s consultation fees that you pay from your own pocket, or that your medical aid pays from a day-to-day benefit or your medical savings account, limited to R 6 000 per policy per year.

BENEFITS NOT SUBJECT TO AN OVERALL POLICY LIMIT (OPL)

The following benefits aren’t subject to the OPL because we give these benefits to you over and above the benefits that form part of the OPL.

PAYOUT BENEFITS

GAP COVER

Going into hospital to have your appendix removed, or having a biopsy done in the doctor’s rooms?

Gap Cover kicks in when your doctor or specialist charges more than the amount your medical aid pays for in- and out-of-hospital medical procedures, as long as it’s paid from a hospital or risk benefit.

We add an additional 500% cover on top of what your medical aid plan gives to cover shortfalls for:

  • medical procedures performed by your doctor and specialist;
  • basic radiology, like black and white x-rays;
  • specialised radiology, like MRI and CT scans;
  • consumable items, like surgical gloves;
  • dental procedures, like wisdom teeth extractions, limited to R 6 000 per policy per year;
  • dental procedures due to accidents or cancer treatment, limited to R 8 000 per policy per year;
  • medication administered during your medical event;
  • pathology;
  • physiotherapy; and
  • Prescribed Minimum Benefit (PMB) medical

 Don’t forget… your medical aid must make payment from a hospital or risk benefit, and not from a day-to-day benefit or your medical savings account.

CASUALTY COVER

ACCIDENT COVER
For the whole family

For immediate medical treatment due to an accident you can go to your nearest medical facility.

ACCIDENTS are unexpected incidents that cause physical injury due to physical impact with someone or something.
IMMEDIATE means within 24-hours from the time of the incident.

What do we cover? Everything related to your casualty event, like:

  • co-payments and facility fees;
  • doctors’ consultation fees;
  • basic radiology, specialised radiology and pathology;
  • medication administered during your casualty event; and
  • external medical items that’s given to you at the medical facility, like a neck brace.

Need a follow-up visit to a medical facility after an accidental event to have stitches or a cast removed? We’ll refund that too.

ILLNESS COVER
Only for children younger than 8 years of age

If your child who’s younger than 8 gets sick after-hours, we’ll cover the cost of a visit to a casualty facility and all the healthcare providers’ accounts related to the visit.

WHEN IS AFTER-HOURS? Mondays to Fridays between 18:00pm and 07:00am and all-day Saturdays, Sundays and public holidays.

We’ll refund the amount that you pay from your own pocket or that your medical aid pays from a day-to-day benefit or your medical savings account.
Casualty Cover is limited to R 7 000 per policy per year.

TRAUMA COUNSELLING COVER

Sometimes you just need to talk to someone about it. If you’ve:

  • witnessed, or are directly affected by an act of physical violence or an accident;
  • received news of a loved one’s, or of your own diagnosis of a critical illness; or
  • mourn the death of a loved one,

we’ll refund the registered counsellor’s consultation fees that you pay from your own pocket, or that your medical aid pays from a day-to-day benefit or your medical savings account, limited to R 6 000 per policy per year.

BENEFITS NOT SUBJECT TO AN OVERALL POLICY LIMIT (OPL)

The following benefits aren’t subject to the OPL because we give these benefits to you over and above the benefits that form part of the OPL.

PAYOUT BENEFITS

ACCIDENTAL DISABILITY AND DEATH

You and your spouse are covered for a benefit amount of R 6 000 per person if either one of you becomes totally and permanently disabled or passes away due to an accident.

Limited to 1 event per person per year.

FIRST-TIME CANCER DIAGNOSIS

When cancer is diagnosed for the very first time in your life after you’ve joined us, you’ll receive a payout benefit.

Some cancer diagnoses, like Stage 1 breast or prostate cancer, aren’t covered.
Our Benefit Exclusions explain the terms and conditions in more detail.

Limited to R 5 000 per person per lifetime if cancer is diagnosed before the age of 65.

LIFESTYLE BENEFITS

Our Lifestyle Benefits are complimentary and don’t cost you a cent.

EXTRA HIGH SCHOOL LEARNING SUPPORT

Based on the CAPS curriculum, your Gr.8 to Gr.12 high school child gets instant access to content that’ll help them study, improve their knowledge and boost their marks.

FUEL REWARDS

Fill up at any SHELL service station and get rewarded with 22 cents per litre of diesel and 15 cents per litre of petrol. Subject to change without prior notice.

INTERNATIONAL TRAVEL INSURANCE

Planning on travelling? Happy days.

We cover you for acute illness and injury when you travel outside of South African borders.

Whether you travel alone or with family members, cover is limited to 1 trip per policy per year to a maximum of 31 days.

10 MONTH LIMITED PAYOUT BENEFIT, WAITING PERIODS, BENEFIT AND GENERAL EXCLUSIONS

10 MONTH LIMITED PAYOUT BENEFIT

If you claim from our GAP COVER within the first 10 months of cover for a medical event related to:

  • adenoidectomy;
  • tonsillectomy;
  • myringotomy/grommets;
  • cardiovascular procedures;
  • cataract removal;
  • dentistry;
  • hernia repairs;
  • joint replacements;
  • MRI, CT and PET scans;
  • nasal and sinus surgery;
  • pregnancy and childbirth;
  • spinal procedures;
  • scopes (including medical events where a scope is used); or
  • hysterectomy (full cover applies if required due to cancer when diagnosed after the General Waiting Period),

 
we’ll cover only 20% of the approved claim amount subject to benefit limits where applicable.

If your medical event is related to a medical condition that you received advice or treatment for within 12 months before the start date of your policy, your claim will be subject to a Pre-Existing Condition Waiting Period.

Accidental events don’t form part of the 10 Month Limited Payout Benefit and aren’t subject to any waiting periods.

WAITING PERIODS

Waiting periods apply from the start date of your policy, from the effective option change date when you upgrade your policy, and from each person’s cover start date when they’re added after the policy’s start date.

3 MONTH GENERAL WAITING PERIOD
We don’t cover you during this period unless you claim for accidental events that occur after your cover start date.

12 MONTH PRE-EXISTING CONDITION WAITING PERIOD
We don’t cover you during this period for investigations, medical procedures, surgeries or treatments related to any illness or medical condition that was diagnosed or that you received advice or treatment for within 12 months before your policy’s start date.

BENEFIT & GENERAL EXCLUSIONS

KEY BENEFITS SUBJECT TO THE OVERALL POLICY LIMIT (OPL)

1.  GAP COVER

WHAT OUR BENEFIT DOESN’T COVER

We don’t cover coded lines on your healthcare or service providers’ accounts:

1.1  if your medical aid paid it as an exception to the rule.
1.2  if your medical aid didn’t partly pay it from a hospital or risk benefit.
1.3  if your medical aid fully paid it from a hospital or risk benefit, as there’ll be no claimable shortfall.
1.4  if your medical aid partly or fully paid it from a day-to-day benefit or your medical savings account.
1.5  if your medical aid processed it against your self-payment gap.
(A self-payment gap applies when you’ve used the funds in your medical savings account, after which you have to pay your day-to-day medical expenses from your own pocket up to a specific amount.)
1.6  if it’s for upfront fees or deposits that your healthcare providers ask you to pay to them directly.
1.7  if it’s for out-patient consultation fees, unless a medical procedure was performed at the same time.
1.8  if it’s for hospital accounts, unless you’re claiming for consumable items or medication that your medical aid partly paid from a hospital or risk benefit.
1.9  if it’s for allied healthcare providers, unless your policy provides a benefit that covers it.
(Allied healthcare providers are healthcare professionals associated with your medical event who aren’t doctors or specialists. We only cover the following allied healthcare providers:
1.9.1  clinical perfusionists;
1.9.2  dental hygienists;
1.9.3  midwives;
1.9.4  nurses; and
1.9.5  physiotherapists.)
1.10  if your medical aid didn’t partly pay it because a benefit limit provided by your medical aid plan’s been reached.
1.11  at more than 20% of the approved claim amount if you claim in the first 10 months of cover from a benefit limit provided by your policy, for medical events related to:
1.11.1  adenoidectomy;
1.11.2  tonsillectomy;
1.11.3  myringotomy/grommets;
1.11.4  cardiovascular procedures;
1.11.5  cataract removal;
1.11.6  dentistry;
1.11.7  hernia repairs;
1.11.8  hysterectomy (unless it’s for cancer that’s diagnosed after a General Waiting Period);
1.11.9  joint replacements;
1.11.10  MRI, CT and PET scans;
1.11.11  nasal and sinus surgery;
1.11.12  pregnancy and childbirth;
1.11.13  spinal procedures; or
1.11.14  scopes (including medical events where a scope is used).

2.  CASUALTY COVER

WHAT OUR BENEFIT DOESN’T COVER

We don’t cover coded lines on your healthcare or service providers’ accounts:

2.1  if it’s not related to an accident. 
2.2  if it’s not related to illness of your child dependant younger than 8.
2.3  that are related to an accident, but medical treatment wasn’t provided within 24-hours from the time of the incident.
2.4  if it’s for medication that wasn’t administered during your casualty event,  during follow-up visits to a registered medical facility after an accidental event, medication that you take home or that’s prescribed to collect at a pharmacy. 
2.5  if it’s for external medical items that you didn’t receive at the registered medical facility during your initial casualty visit. 
2.6  if it’s for follow-up visits that aren’t related to accidental events.
2.7  if it’s for follow-up visits to a registered medical facility that are related to an accident, but follow-up visits occurs after a hospital admission.
(When you’re admitted to hospital after being treated at a registered medical facility, the hospital admission will be a new event and return visits for follow-up treatment won’t be assessed under Casualty Cover.)

2.8  if it’s for medical treatment due to illness provided to your child younger than 8, but medical treatment wasn’t provided at a registered casualty facility.
2.9  if it’s for treatment due to illness provided to your child younger than 8 at a registered casualty facility, but your child didn’t receive after-hours medical treatment.
(After-hours is Mondays to Fridays between 18:00pm and 07:00am and all-day Saturdays, Sundays and public holidays.)

2.10  if it’s for medical treatment due to illness provided to your child aged 8 or older.
2.11  that your medical aid fully paid from a risk benefit, as there’ll be no claimable event.

3.  TRAUMA COUNSELLING COVER

WHAT OUR BENEFIT DOESN’T COVER

We don’t cover coded lines on your healthcare providers’ accounts:

3.1  if you haven’t witnessed or aren’t directly affected by an act of physical violence or an accident.
3.2  if you aren’t affected by a loved one’s diagnosis of a critical illness or death, or by your own diagnosis of a critical illness.
3.3  if your medical aid fully paid it from a risk benefit, as there’ll be no claimable event.
3.4  if your counsellors aren’t registered with a recognised South African regulatory body.

BENEFIT NOT SUBJECT TO THE OVERALL POLICY LIMIT (OPL)

4.  PAYOUT BENEFIT

4.1  ACCIDENTAL DISABILITY AND DEATH

WHAT OUR BENEFIT DOESN’T COVER

We don’t cover instances:

4.1.1  if total and permanent disability or death isn’t due to an accident.
4.1.2  if it exceeds one claimable event per qualifying person in a benefit year.
4.1.3  if a death certificate or proof of disability isn’t provided, where applicable.

4.2  FIRST-TIME CANCER DIAGNOSIS

WHAT OUR BENEFIT DOESN’T COVER

We don’t cover:

4.2.1  a cancer diagnosis if it’s not the first cancer diagnosed in your life.
4.2.2  a cancer diagnosis if it’s diagnosed before the first day your cover starts with us or during a General Waiting Period.
4.2.3  you if pre-cancer cells have been found but a cancer diagnosis hasn’t been confirmed.
4.2.4  cancer of the skin, unless cancerous moles have invaded surrounding or underlying tissue.
4.2.5  a cancer diagnosis if cancerous cells haven’t invaded surrounding or underlying tissue.
4.2.6  Stage 1 breast or prostate cancer.
4.2.7  a cancer diagnosis if it’s diagnosed at age 65 or older.

GENERAL EXCLUSIONS

 We do not cover healthcare or service providers’ accounts related to any medical procedure, treatment, hospitalisation, illness, disease, loss, damage, death, bodily injury or liability for:

  1. events that occurred when you were not an insured person.
  2. events that occur during a policy waiting period unless it is for accidental events.
  3. events where your policy’s overall policy limit or a benefit limit has been reached.
  4. amounts that exceed the additional 500% cover that your policy provides.
  5. events where your policy does not provide the right benefit to claim from.
  6. events that could be covered under more than one benefit provided by your policy, but because your initial medical event has been assessed and registered under a specific key benefit, continuation of treatment as a result of your initial medical event or events that follow your initial medical event, will not be assessed under another benefit.
  7. claims that we have assessed as Prescribed Minimum Benefit (PMB) medical procedures that your medical aid reviews afterwards, and partly or fully pays according to the agreed payment arrangement your medical aid has with your healthcare or service provider.
  8. events where you did not obtain pre-authorisation from your medical aid, or where you did not follow your medical aid’s rules.
  9. maxillofacial surgery and related medical conditions or procedures, unless it is related to accidental injury or cancer.
  10. prescription medication that you collect at a pharmacy or medication that is given to you to take home, unless your policy has a benefit that covers it.
  11. external prostheses, like artificial limbs.
  12. external medical items, like crutches and birthing pools.
  13. mechanical or computerised devices, like ventilators, unless your policy has a benefit that covers it.
  14. co-payments related to robotic surgery, unless your policy has a benefit that covers it.
  15. artificial insemination, infertility treatment, procedures or contraceptives, unless you are claiming for tubal ligation, a vasectomy or a contraceptive device implant if your policy has a benefit that covers it.
  16. obesity and bariatric surgery.
  17. reconstructive cosmetic surgery.
  18. a breast reconstruction if it is not the first breast reconstruction in your lifetime.
    (A breast reconstruction can be an implant or removal of a breast implant.)
  19. home nursing, admission to a step-down or sub-acute facility, like a frail care centre, rehabilitation facility and hospice, unless your policy has a benefit that covers it.
  20. mood disorders, emotional or mental illnesses, unless you are claiming for counselling under our Trauma Counselling Cover benefit.
  21. sleeping disorders.
  22. stem cell harvesting or treatment.
  23. costs related to medical reports.
  24. claims where we have negotiated discounts with your healthcare or service providers and paid them in full.
  25. claims that are resubmitted due to your healthcare or service provider increasing their fees resulting in additional shortfalls, but your claim has already been finalised by us.
  26. information that you did not tell us about that can affect the assessment or acceptance of risk.
  27. events that are covered by more than one Gap Cover Insurer.
  28. routine physical, diagnostic procedures or examinations that you go for as a standard and not because you require medical attention, unless your policy has a benefit that covers it.
  29. transport charges and healthcare services that are provided to you while being transported in an emergency vehicle, vessel or aircraft.
  30. deliberate criminal or fraudulent acts, or any illegal activity conducted by you or a member of your household which directly or indirectly results in loss, damage or injury.
  31. attempted suicide or intentional self-injury.
  32. deliberate exposure to exceptional danger unless you attempt to save a human life.
  33. events where the use of drugs or alcohol is involved.
  34. riots, wars, political acts, public disorder, terrorism, civil commotions, labour disturbances, strikes, lock-out or any attempt to such acts.
  35. active military, police or police reservist activities while you are on active duty.
  36. 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.
  37. events that are covered by legislation, like contractual liability and consequential loss.

Our Gap Cover policy is not a medical aid, does not provide similar cover as that of a medical aid and cannot be substituted for medical aid membership.

ACCIDENTAL DISABILITY AND DEATH

You and your spouse are covered for a benefit amount of R 6 000 per person if either one of you becomes totally and permanently disabled or passes away due to an accident.

Limited to 1 event per person per year.

FIRST-TIME CANCER DIAGNOSIS

When cancer is diagnosed for the very first time in your life after you’ve joined us, you’ll receive a payout benefit.

Some cancer diagnoses, like Stage 1 breast or prostate cancer, aren’t covered.
Our Benefit Exclusions explain the terms and conditions in more detail.

Limited to R 5 000 per person per lifetime if cancer is diagnosed before the age of 65.

LIFESTYLE BENEFITS

Our Lifestyle Benefits are complimentary and don’t cost you a cent.

EXTRA HIGH SCHOOL LEARNING SUPPORT

Based on the CAPS curriculum, your Gr.8 to Gr.12 high school child gets instant access to content that’ll help them study, improve their knowledge and boost their marks.

FUEL REWARDS

Fill up at any SHELL service station and get rewarded with 22 cents per litre of diesel and 15 cents per litre of petrol. Subject to change without prior notice.

INTERNATIONAL TRAVEL INSURANCE

Planning on travelling? Happy days.

We cover you for acute illness and injury when you travel outside of South African borders.

Whether you travel alone or with family members, cover is limited to 1 trip per policy per year to a maximum of 31 days.

10 MONTH LIMITED PAYOUT BENEFIT, WAITING PERIODS, BENEFIT AND GENERAL EXCLUSIONS

10 MONTH LIMITED PAYOUT BENEFIT

If you claim from our GAP COVER within the first 10 months of cover for a medical event related to:

  • adenoidectomy;
  • tonsillectomy;
  • myringotomy/grommets;
  • cardiovascular procedures;
  • cataract removal;
  • dentistry;
  • hernia repairs;
  • joint replacements;
  • MRI, CT and PET scans;
  • nasal and sinus surgery;
  • pregnancy and childbirth;
  • spinal procedures;
  • scopes (including medical events where a scope is used); or
  • hysterectomy (full cover applies if required due to cancer when diagnosed after the General Waiting Period),

 
we’ll cover only 20% of the approved claim amount subject to benefit limits where applicable.

If your medical event is related to a medical condition that you received advice or treatment for within 12 months before the start date of your policy, your claim will be subject to a Pre-Existing Condition Waiting Period.

Accidental events don’t form part of the 10 Month Limited Payout Benefit and aren’t subject to any waiting periods.

WAITING PERIODS

Waiting periods apply from the start date of your policy, from the effective option change date when you upgrade your policy, and from each person’s cover start date when they’re added after the policy’s start date.

3 MONTH GENERAL WAITING PERIOD
We don’t cover you during this period unless you claim for accidental events that occur after your cover start date.

12 MONTH PRE-EXISTING CONDITION WAITING PERIOD
We don’t cover you during this period for investigations, medical procedures, surgeries or treatments related to any illness or medical condition that was diagnosed or that you received advice or treatment for within 12 months before your policy’s start date.

BENEFIT & GENERAL EXCLUSIONS

KEY BENEFITS SUBJECT TO THE OVERALL POLICY LIMIT (OPL)

1.  GAP COVER

WHAT OUR BENEFIT DOESN’T COVER

We don’t cover coded lines on your healthcare or service providers’ accounts:

1.1  if your medical aid paid it as an exception to the rule.
1.2  if your medical aid didn’t partly pay it from a hospital or risk benefit.
1.3  if your medical aid fully paid it from a hospital or risk benefit, as there’ll be no claimable shortfall.
1.4  if your medical aid partly or fully paid it from a day-to-day benefit or your medical savings account.
1.5  if your medical aid processed it against your self-payment gap.
(A self-payment gap applies when you’ve used the funds in your medical savings account, after which you have to pay your day-to-day medical expenses from your own pocket up to a specific amount.)
1.6  if it’s for upfront fees or deposits that your healthcare providers ask you to pay to them directly.
1.7  if it’s for out-patient consultation fees, unless a medical procedure was performed at the same time.
1.8  if it’s for hospital accounts, unless you’re claiming for consumable items or medication that your medical aid partly paid from a hospital or risk benefit.
1.9  if it’s for allied healthcare providers, unless your policy provides a benefit that covers it.
(Allied healthcare providers are healthcare professionals associated with your medical event who aren’t doctors or specialists. We only cover the following allied healthcare providers:
1.9.1  clinical perfusionists;
1.9.2  dental hygienists;
1.9.3  midwives;
1.9.4  nurses; and
1.9.5  physiotherapists.)
1.10  if your medical aid didn’t partly pay it because a benefit limit provided by your medical aid plan’s been reached.
1.11  at more than 20% of the approved claim amount if you claim in the first 10 months of cover from a benefit limit provided by your policy, for medical events related to:
1.11.1  adenoidectomy;
1.11.2  tonsillectomy;
1.11.3  myringotomy/grommets;
1.11.4  cardiovascular procedures;
1.11.5  cataract removal;
1.11.6  dentistry;
1.11.7  hernia repairs;
1.11.8  hysterectomy (unless it’s for cancer that’s diagnosed after a General Waiting Period);
1.11.9  joint replacements;
1.11.10  MRI, CT and PET scans;
1.11.11  nasal and sinus surgery;
1.11.12  pregnancy and childbirth;
1.11.13  spinal procedures; or
1.11.14  scopes (including medical events where a scope is used).

2.  CASUALTY COVER

WHAT OUR BENEFIT DOESN’T COVER

We don’t cover coded lines on your healthcare or service providers’ accounts:

2.1  if it’s not related to an accident. 
2.2  if it’s not related to illness of your child dependant younger than 8.
2.3  that are related to an accident, but medical treatment wasn’t provided within 24-hours from the time of the incident.
2.4  if it’s for medication that wasn’t administered during your casualty event,  during follow-up visits to a registered medical facility after an accidental event, medication that you take home or that’s prescribed to collect at a pharmacy. 
2.5  if it’s for external medical items that you didn’t receive at the registered medical facility during your initial casualty visit. 
2.6  if it’s for follow-up visits that aren’t related to accidental events.
2.7  if it’s for follow-up visits to a registered medical facility that are related to an accident, but follow-up visits occurs after a hospital admission.
(When you’re admitted to hospital after being treated at a registered medical facility, the hospital admission will be a new event and return visits for follow-up treatment won’t be assessed under Casualty Cover.)

2.8  if it’s for medical treatment due to illness provided to your child younger than 8, but medical treatment wasn’t provided at a registered casualty facility.
2.9  if it’s for treatment due to illness provided to your child younger than 8 at a registered casualty facility, but your child didn’t receive after-hours medical treatment.
(After-hours is Mondays to Fridays between 18:00pm and 07:00am and all-day Saturdays, Sundays and public holidays.)

2.10  if it’s for medical treatment due to illness provided to your child aged 8 or older.
2.11  that your medical aid fully paid from a risk benefit, as there’ll be no claimable event.

3.  TRAUMA COUNSELLING COVER

WHAT OUR BENEFIT DOESN’T COVER

We don’t cover coded lines on your healthcare providers’ accounts:

3.1  if you haven’t witnessed or aren’t directly affected by an act of physical violence or an accident.
3.2  if you aren’t affected by a loved one’s diagnosis of a critical illness or death, or by your own diagnosis of a critical illness.
3.3  if your medical aid fully paid it from a risk benefit, as there’ll be no claimable event.
3.4  if your counsellors aren’t registered with a recognised South African regulatory body.

BENEFIT NOT SUBJECT TO THE OVERALL POLICY LIMIT (OPL)

4.  PAYOUT BENEFIT

4.1  ACCIDENTAL DISABILITY AND DEATH

WHAT OUR BENEFIT DOESN’T COVER

We don’t cover instances:

4.1.1  if total and permanent disability or death isn’t due to an accident.
4.1.2  if it exceeds one claimable event per qualifying person in a benefit year.
4.1.3  if a death certificate or proof of disability isn’t provided, where applicable.

4.2  FIRST-TIME CANCER DIAGNOSIS

WHAT OUR BENEFIT DOESN’T COVER

We don’t cover:

4.2.1  a cancer diagnosis if it’s not the first cancer diagnosed in your life.
4.2.2  a cancer diagnosis if it’s diagnosed before the first day your cover starts with us or during a General Waiting Period.
4.2.3  you if pre-cancer cells have been found but a cancer diagnosis hasn’t been confirmed.
4.2.4  cancer of the skin, unless cancerous moles have invaded surrounding or underlying tissue.
4.2.5  a cancer diagnosis if cancerous cells haven’t invaded surrounding or underlying tissue.
4.2.6  Stage 1 breast or prostate cancer.
4.2.7  a cancer diagnosis if it’s diagnosed at age 65 or older.

GENERAL EXCLUSIONS

 We do not cover healthcare or service providers’ accounts related to any medical procedure, treatment, hospitalisation, illness, disease, loss, damage, death, bodily injury or liability for:

  1. events that occurred when you were not an insured person.
  2. events that occur during a policy waiting period unless it is for accidental events.
  3. events where your policy’s overall policy limit or a benefit limit has been reached.
  4. amounts that exceed the additional 500% cover that your policy provides.
  5. events where your policy does not provide the right benefit to claim from.
  6. events that could be covered under more than one benefit provided by your policy, but because your initial medical event has been assessed and registered under a specific key benefit, continuation of treatment as a result of your initial medical event or events that follow your initial medical event, will not be assessed under another benefit.
  7. claims that we have assessed as Prescribed Minimum Benefit (PMB) medical procedures that your medical aid reviews afterwards, and partly or fully pays according to the agreed payment arrangement your medical aid has with your healthcare or service provider.
  8. events where you did not obtain pre-authorisation from your medical aid, or where you did not follow your medical aid’s rules.
  9. maxillofacial surgery and related medical conditions or procedures, unless it is related to accidental injury or cancer.
  10. prescription medication that you collect at a pharmacy or medication that is given to you to take home, unless your policy has a benefit that covers it.
  11. external prostheses, like artificial limbs.
  12. external medical items, like crutches and birthing pools.
  13. mechanical or computerised devices, like ventilators, unless your policy has a benefit that covers it.
  14. co-payments related to robotic surgery, unless your policy has a benefit that covers it.
  15. artificial insemination, infertility treatment, procedures or contraceptives, unless you are claiming for tubal ligation, a vasectomy or a contraceptive device implant if your policy has a benefit that covers it.
  16. obesity and bariatric surgery.
  17. reconstructive cosmetic surgery.
  18. a breast reconstruction if it is not the first breast reconstruction in your lifetime.
    (A breast reconstruction can be an implant or removal of a breast implant.)
  19. home nursing, admission to a step-down or sub-acute facility, like a frail care centre, rehabilitation facility and hospice, unless your policy has a benefit that covers it.
  20. mood disorders, emotional or mental illnesses, unless you are claiming for counselling under our Trauma Counselling Cover benefit.
  21. sleeping disorders.
  22. stem cell harvesting or treatment.
  23. costs related to medical reports.
  24. claims where we have negotiated discounts with your healthcare or service providers and paid them in full.
  25. claims that are resubmitted due to your healthcare or service provider increasing their fees resulting in additional shortfalls, but your claim has already been finalised by us.
  26. information that you did not tell us about that can affect the assessment or acceptance of risk.
  27. events that are covered by more than one Gap Cover Insurer.
  28. routine physical, diagnostic procedures or examinations that you go for as a standard and not because you require medical attention, unless your policy has a benefit that covers it.
  29. transport charges and healthcare services that are provided to you while being transported in an emergency vehicle, vessel or aircraft.
  30. deliberate criminal or fraudulent acts, or any illegal activity conducted by you or a member of your household which directly or indirectly results in loss, damage or injury.
  31. attempted suicide or intentional self-injury.
  32. deliberate exposure to exceptional danger unless you attempt to save a human life.
  33. events where the use of drugs or alcohol is involved.
  34. riots, wars, political acts, public disorder, terrorism, civil commotions, labour disturbances, strikes, lock-out or any attempt to such acts.
  35. active military, police or police reservist activities while you are on active duty.
  36. 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.
  37. events that are covered by legislation, like contractual liability and consequential loss.

Our Gap Cover policy is not a medical aid, does not provide similar cover as that of a medical aid and cannot be substituted for medical aid membership.