OPTIMISER RANGE

Our individual and corporate Access options are our booster options that cover specific medical procedures and events that your medical aid plan excludes from cover.

 

OPTIMISER RANGE

Our individual and corporate Access options are our booster options that cover specific medical procedures and events that your medical aid plan excludes from cover.

 

MONTHLY PREMIUMS

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.

CORPORATE ACCESS

We cover employer groups if 10 or more employees join through their employer.
Ask your employer if your spouse and/or dependants may also join.

Premiums for employer groups are determined by factors like the employer group’s average age and if cover for employees is compulsory or voluntary.

KEY BENEFITS SUBJECT TO AN OVERALL POLICY LIMIT (OPL)

An OPL of R 173 000 per policy per year applies to the following benefits regardless of whether you’re covered as an individual or a family. This means that all approved claim amounts will get deducted off the OPL.

ACCESS COVER

Need one or more of the below listed medical procedures, but your medical aid excludes it from cover?

We’ve got the key because the cost of your admission to a hospital or day clinic and all your related healthcare providers’ accounts will be covered by us, limited to the rand amounts as shown below:

MEDICAL PROCEDURE/EVENT NOT COVERED BY YOUR MEDICAL AID ACCESS COVER PROVIDES
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 procedure, device, processor and hearing aids)

 

R 80 000

Dental procedures for impacted teeth for children younger than 18 R 14 000
Dental procedures for reconstructive surgery required due to an accidental event R 80 000
Endoscopic procedures R 5 000
Functional nasal surgery R 23 000
Joint replacement surgery (including the internal prosthetic device) R 50 000
Knee or shoulder surgery R 25 000
MRI or CT scan required due to an accidental event R 10 000
Non-cancerous breast conditions
(including breast reconstruction of a breast not affected by cancer)

 

R 20 000

Oesophageal reflux and hiatus hernia surgery R 55 000
Removal of varicose veins R 20 000
Skin disorders (including benign growths or lipomas) R 20 000

Benefits are available to every person on the policy, but the benefit limits are shared subject to the OPL.

YOUR NEXT STEP
  • When your doctor or specialist lets you know that you need any of the listed medical procedures or treatments, you must get cost estimates from your preferred hospital or day clinic and all the related healthcare providers.
  • We’ll issue a guarantee of payment as an undertaking to pay your doctor, specialist, hospital or day clinic directly after your claim is approved.

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

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 2 000 per policy per year.

BENEFIT NOT SUBJECT TO AN OVERALL POLICY LIMIT (OPL)

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

PAYOUT BENEFIT

ACCIDENTAL DISABILITY AND DEATH

You and your spouse are covered for a benefit amount of R 5 000 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.

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.

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

10 MONTH LIMITED PAYOUT BENEFIT

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

  • arthroscopic surgery;
  • back or neck surgery;
  • bunion surgery;
  • cochlear implant, auditory brain implant and internal nerve stimulator surgery (including the procedure, device, processor and hearing aids);
  • dental procedures for impacted teeth for children younger than 18;
  • endoscopic procedures;
  • functional nasal surgery;
  • joint replacement surgery (incl. internal prosthetic devices);
  • knee or shoulder surgery;
  • non-cancerous breast conditions (including breast reconstruction of a breast not affected by cancer);
  • oesophageal reflux and hiatus hernia surgery;
  • removal of varicose veins; or
  • skin disorders (including benign growths or lipomas),

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

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.

EMPLOYER GROUPS: The percentage that applies to employer groups under the 10 Month Limited Payout Benefit is subject to the quote accepted by your employer.

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.

EMPLOYER GROUPS: Waiting periods that apply to employer groups are subject to the quote accepted by your employer.

BENEFIT EXCLUSIONS

ACCESS 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 processed it against your self-payment gap.
 (A self-payment gap applies when you’ve used the funds in your medical savings account and pay your day-to-day medical expenses from your own pocket,  up to a specific amount.)

1.3  if it’s for medical procedures or treatments that your medical aid plan doesn’t exclude from cover.
1.4  if it’s for medical procedures or treatments that your medical aid plan excludes, but it’s not the medical procedures or treatments that we cover.
1.5  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:
1.5.1  arthroscopic surgery;
1.5.2  back or neck surgery;
1.5.3  bunion surgery;
1.5.4  cochlear implant, auditory brain implant and internal nerve stimulator surgery (including the procedure, device, processor and hearing aids);
1.5.5  dental procedures for impacted teeth for children younger than 18;
1.5.7  functional nasal surgery;
1.5.8  joint replacement surgery;
1.5.9  knee or shoulder surgery;
1.5.10  non-cancerous breast conditions (including breast reconstruction of a breast not affected by cancer);
1.5.11  oesophageal reflux and hiatus hernia surgery;
1.5.12  removal of varicose veins; or           
1.5.13  skin disorders (including benign growths or lipomas).
(Employer groups will receive a payout of between 20% and 100% under the 10 Month Limited Payout Benefit subject to a quote.)

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.

BENEFIT NOT SUBJECT TO THE OVERALL POLICY LIMIT (OPL)

3.  PAYOUT BENEFIT

ACCIDENTAL DISABILITY AND DEATH

WHAT OUR BENEFIT DOESN’T COVER

We don’t cover instances:
3.1  if total and permanent disability or death isn’t due to an accident.
3.2  if it exceeds one claimable event per qualifying person in a benefit year.
3.3  if a death certificate or proof of disability isn’t provided, where applicable.

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. events where your policy does not provide the right benefit to claim from.
  5. 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.
  6. 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.
  7. events where you did not obtain pre-authorisation from your medical aid, or where you did not follow your medical aid’s rules.
  8. prescription medication that you collect at a pharmacy or medication that is given to you to take home.
  9. external prostheses, like artificial limbs.
  10. external medical items, like crutches and birthing pools.
  11. mechanical or computerised devices, like ventilators, unless your policy has a benefit that covers it.
  12. co-payments related to robotic surgery.
  13. artificial insemination, infertility treatment, procedures or contraceptives.
  14. obesity and bariatric surgery.
  15. reconstructive cosmetic surgery.
  16. a breast reconstruction if it is not the first breast reconstruction in your lifetime.
  17. (A breast reconstruction can be an implant or removal of a breast implant.)

  18. home nursing, admission to a step-down or sub-acute facility, like a frail care centre, rehabilitation facility and hospice.
  19. mood disorders, emotional or mental illnesses.
  20. sleeping disorders.
  21. stem cell harvesting or treatment.
  22. costs related to medical reports.
  23. claims where we have negotiated discounts with your healthcare or service providers and paid them in full.
  24. information that you did not tell us about that can affect the assessment or acceptance of risk.
  25. events that are covered by more than one Gap Cover Insurer.
  26. 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.
  27. transport charges and healthcare services that are provided to you while being transported in an emergency vehicle, vessel or aircraft.
  28. 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.
  29. attempted suicide or intentional self-injury.
  30. deliberate exposure to exceptional danger unless you attempt to save a human life.
  31. events where the use of drugs or alcohol is involved.
  32. riots, wars, political acts, public disorder, terrorism, civil commotions, labour disturbances, strikes, lock-out or any attempt to such acts.
  33. active military, police or police reservist activities while you are on active duty.
  34. 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.
  35. 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.