GENERAL AND BENEFIT EXCLUSIONS
The below benefit exclusions may apply to your Gap Cover option, depending on the option you’re covered on. General exclusions apply to all policies.
KEY BENEFITS SUBJECT TO THE OVERALL POLICY LIMIT (OPL)
1. GAP COVER
Our benefit 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 the payment your medical aid makes isn’t from your medical savings account.
We add an additional 300% or 500% cover on top of what your medical aid plan gives to cover shortfalls.
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 benefit.
1.3 if your medical aid fully paid it from a hospital benefit, as there’ll be no claimable shortfall.
1.4 if your medical aid partly or fully paid it from 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 pre-natal (pre-birth) consultations, including all ancillary procedures or investigations performed during, or following your consultation.
1.9 if it’s for hospital accounts, unless you’re claiming for consumable items or medication that your medical aid partly paid from a hospital benefit.
1.10 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:
1.10.1 clinical perfusionists;
1.10.2 dental hygienists;
1.10.3 midwives;
1.10.4 nurses; and
1.10.5 physiotherapists.)
1.11 if your medical aid didn’t partly pay it because a benefit limit provided by your medical aid plan’s been reached.
1.12 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:
1.12.1 adenoidectomy;
1.12.2 tonsillectomy;
1.12.3 myringotomy/grommets;
1.12.4 cardiovascular procedures;
1.12.5 cataract removal;
1.12.6 dentistry;
1.12.7 hernia repairs;
1.12.8 hysterectomy (unless it’s for cancer that’s diagnosed after a General Waiting Period);
1.12.9 joint replacements;
1.12.10 MRI, CT and PET scans;
1.12.11 nasal and sinus surgery;
1.12.12 pregnancy and childbirth;
1.12.13 spinal procedures; or
1.12.14 scopes (including medical events where a scope is used).
(Employer groups will receive a payout of between 20% and 100% under the 10 Month Limited Payout Benefit subject to a quote.)
2. CO-PAYMENT COVER
When your medical aid asks you to pay upfront co-payments or deductibles for in- and out-of-hospital medical procedures, we’ll refund you if you paid the co-payment or deductible from your own pocket, or if your medical aid paid it from your medical savings account.
WHAT OUR BENEFIT DOESN’T COVER
We don’t refund co-payments or deductibles:
2.1 if your medical aid paid it as an exception to the rule.
2.2 if you didn’t obtain pre-authorisation before your medical event.
2.3 if you didn’t follow your medical aid’s rules.
2.4 if you used healthcare or service providers that don’t form part of your medical aid plan’s preferred provider network (non-designated provider), unless your policy provides a benefit that covers it.
2.5 that your healthcare providers ask you to pay to them directly.
(This is referred to as split-billing. We only refund co-payments or deductibles that your medical aid asks for.)
2.6 if it’s for co-payments or deductibles that you’re responsible to pay to your healthcare or service provider because your medical aid imposes it, but what you paid is more than the amount your medical aid imposes.
(Any excess amounts that you pay to a provider will be for your own pocket.)
2.7 if it’s for co-payments or deductibles that you didn’t pay from your own pocket, or that your medical aid didn’t pay from your medical savings account.
2.8 if it’s for cancer treatment.
2.9 if it’s for out-patient consultation fees.
2.10 if it’s for chronic, acute, formulary, non-formulary, or over-the-counter medication.
2.11 if it’s for robotic surgery, or for the use of other specialised mechanical or computerised items or equipment, unless your policy provides a benefit that covers it.
2.12 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:
2.12.1 adenoidectomy;
2.12.2 tonsillectomy;
2.12.3 myringotomy/grommets;
2.12.4 cardiovascular procedures;
2.12.5 cataract removal;
2.12.6 dentistry;
2.12.7 hernia repairs;
2.12.8 hysterectomy (unless it’s for cancer that’s diagnosed after a General Waiting Period);
2.12.9 joint replacements;
2.12.10 MRI, CT and PET scans;
2.12.11 nasal and sinus surgery;
2.12.12 pregnancy and childbirth;
2.12.13 spinal procedures; or
2.12.14 scopes (including medical events where a scope is used).
(Employer groups will receive a payout of between 20% and 100% under the 10 Month Limited Payout Benefit subject to a quote.)
3. SUB-LIMIT COVER
This benefit covers the shortfalls on specific medical procedures or treatments when your medical aid pays some of the cost from a sub-limit or annual limit, but doesn’t cover the full cost.
WHAT OUR BENEFIT DOESN’T COVER
We don’t cover coded lines on your healthcare or service providers’ accounts:
3.1 if your medical aid paid it as an exception to the rule.
3.2 if it’s for healthcare services that your medical aid plan applies a sub-limit or annual limit to, but it’s not for the healthcare services that our benefit covers.
3.3 if your medical aid didn’t partly pay it from a sub-limit or annual limit.
3.4 if you didn’t follow your medical aid’s rules.
3.5 if you used healthcare or service providers that don’t form part of your medical aid’s preferred provider network.
3.6 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:
3.6.1 adenoidectomy;
3.6.2 tonsillectomy;
3.6.3 myringotomy/grommets;
3.6.4 cardiovascular procedures;
3.6.5 cataract removal;
3.6.6 dentistry;
3.6.7 hernia repairs;
3.6.8 hysterectomy (unless it’s for cancer that’s diagnosed after a General Waiting Period);
3.6.9 joint replacements;
3.6.10 MRI, CT and PET scans;
3.6.11 nasal and sinus surgery;
3.6.12 pregnancy and childbirth;
3.6.13 spinal procedures; or
3.6.14 scopes (including medical events where a scope is used).
(Employer groups will receive a payout of between 20% and 100% under the 10 Month Limited Payout Benefit subject to a quote.)
4. CANCER COVER
4.1 BREAST RECONSTRUCTION
If the cost of a breast reconstruction of an unaffected breast isn’t covered by your medical aid plan, we’ve got you.
WHAT OUR BENEFIT DOESN’T COVER
We don’t cover coded lines on your healthcare or service providers’ accounts:
4.1.1 if your medical aid paid it as an exception to the rule.
4.1.2 if it’s for a mastectomy (removal) of an unaffected breast.
4.1.3 if it’s for a breast reconstruction of an unaffected breast, but the cancer diagnosis of the affected breast isn’t Stage 2 or a higher breast cancer diagnosis.
4.1.4 if it’s for a breast reconstruction of an unaffected breast, but the breast reconstruction isn’t done at the same time as a bilateral mastectomy (removal of both breasts), and the breast reconstruction of the affected breast.
4.1.5 if it’s for a breast reconstruction of an unaffected breast that your medical aid plan covers, as there’ll be no claimable event.
4.2 CANCER TREATMENT SHORTFALLS
When your healthcare providers charge more than the amount your medical aid pays from an oncology benefit, we’ll cover the difference. We’ll also refund the co-payments that your medical aid asks you to pay when your medical aid plan’s oncology benefit limit is reached.
WHAT OUR BENEFIT DOESN’T COVER
We don’t cover coded lines on your healthcare or service providers’ accounts:
4.2.1 if your medical aid paid it as an exception to the rule.
4.2.2 if it’s for cancer treatment that your medical aid didn’t approve as part of a cancer treatment plan.
4.2.3 if your medical aid fully paid it from an oncology benefit, as there’ll be no claimable shortfall.
4.2.4 if your medical aid partly or fully paid it from your medical savings account.
4.2.5 if you didn’t follow your medical aid’s rules.
4.2.6 if you used healthcare or service providers that don’t form part of your medical aid’s preferred network.
4.2.7 if it’s for co-payments or deductibles that your medical aid asks you to pay before your medical aid plan’s oncology benefit limit is reached.
(We only cover co-payments or deductibles that apply after your medical aid plan’s benefit limit is reached.)
4.2.8 if it’s for secondary co-payments that apply to cancer treatment or cancer medication.
5. TOP-UP COVER
This top-up benefit covers the full cost of an MRI or CT scan when your medical aid plan’s benefit limit is reached.
5.1 MRI AND CT SCAN TOP-UP
WHAT OUR BENEFIT DOESN’T COVER
We don’t cover coded lines on your service providers’ accounts:
5.1.1 if your medical aid paid it as an exception to the rule.
5.1.2 if your medical aid partly or fully paid it from a hospital or specialised radiology benefit, as there’ll be no claimable event.
5.1.3 if your medical aid partly or fully paid it from your medical savings account.
5.1.4 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.)
5.1.5 if your medical aid plan doesn’t provide an MRI or CT scan benefit that you can claim from.
5.1.6 if your medical aid plan’s benefit limit hasn’t been reached.
5.2 CANCER TREATMENT TOP-UP
Need ongoing cancer treatment after your medical aid plan’s oncology benefit is reached?
This benefit covers the cost of ongoing cancer treatment according to the cancer treatment plan that your medical aid approved.
WHAT OUR BENEFIT DOESN’T COVER
We don’t cover coded lines on your healthcare or service providers’ accounts:
5.2.1 if your medical aid paid it as an exception to the rule.
5.2.2 if it’s for cancer treatment that your medical aid didn’t approve as part of a cancer treatment plan.
5.2.3 if your medical aid fully paid it from an oncology benefit, as there’ll be no claimable event.
5.2.4 if it’s for cancer treatment that your medical aid partly or fully paid from your medical savings account. If, however, your medical aid agrees to pay your ongoing cancer treatment from funds that’s available in your medical savings account after the benefit limit is reached, we’ll assess your claim.
5.2.5 if you’ve used healthcare or service providers that don’t form part of your medical aid’s preferred network.
5.3 PHYSICAL REHABILITATION TOP-UP
If you’ve been in an accident and need ongoing physical rehabilitation treatment, we’ll cover the cost when your medical aid plan’s physical rehabilitation benefit is reached.
WHAT OUR BENEFIT DOESN’T COVER
We don’t cover coded lines on your healthcare or service providers’ accounts:
5.3.1 if your medical aid paid it as an exception to the rule.
5.3.2 if it’s not related to an accident.
5.3.3 if it’s for an admission or therapy that your medical aid didn’t approve as part of your physical rehabilitation treatment plan.
5.3.4 if it’s for physical therapy that your medical aid partly or fully paid from medical savings account. If, however, your medical aid agrees to pay your ongoing physical therapy from available funds in your medical savings account after the benefit limit is reached, we’ll assess your claim.
5.3.5 if you’ve used a healthcare or service provider that doesn’t form part of your medical aid’s preferred network.
5.3.6 if it’s for physical therapy provided by healthcare providers outside of the sub-acute or step-down facility, or after you’ve been discharged.
5.3.7 if it’s for healthcare services provided by counsellors, clinical psychologists or psychiatrists.
5.3.8 if your healthcare or service providers aren’t registered with a South African regulatory body.
6. OUT-PATIENT SPECIALIST CONSULTATION COVER
We can help cover the difference between what your specialist charges for virtual or face-to-face consultations and the rate your medical aid plan applies, as long as your medical aid pays some of the cost from a hospital or day-to-day benefit, or from your medical savings account.
WHAT OUR BENEFIT DOESN’T COVER
We don’t cover coded lines on your specialists’ accounts:
6.1 if it’s for out-patient consultations that occur during a General Waiting Period.
6.2 if your medical aid fully paid it, regardless of whether payment is made from a hospital or day-to-day benefit, your medical savings account or a combination thereof, as there’ll be no claimable shortfall.
6.3 if your medical aid didn’t partly pay it from a hospital or day-to-day benefit, or from your medical savings account.
6.4 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.)
6.5 if the difference between what your specialist charged and the amount your medical aid paid is more than your medical aid plan’s rate.
(We’ll cover the difference between what your specialist charged and the amount your medical aid paid.)
6.6 if there’s no difference in cost between what your specialists charged and the rate your medical aid applied to the consultation, as there’ll be no claimable shortfall.
6.7 if it’s not for out-patient consultation fees.
6.8 if it’s for in-hospital consultations.
6.9 We don’t refund what your medical aid pays from your medical savings account.
6.10 Our benefit doesn’t cover any allied healthcare providers accounts.
7. CASUALTY COVER
You’re covered at the nearest registered medical facility when you need immediate medical treatment due to an accident. Children who are 10 years or younger are also covered for after-hours treatment due to illness at a registered casualty facility.
WHAT OUR BENEFIT DOESN’T COVER
We don’t cover coded lines on your healthcare or service providers’ accounts:
7.1 if it’s not related to an accident.
7.2 if it’s not related to illness of your child dependant who’s 10 years or younger.
7.3 that are related to an accident, but medical treatment wasn’t provided within 24-hours from the time of the incident.
7.4 if it’s for medication that wasn’t administered during your casualty event, during a follow-up visit to a registered medical facility after an accidental event, medication that you take home, or that’s prescribed to collect at a pharmacy.
7.5 if it’s for external medical items that you didn’t receive at the registered medical facility during your initial casualty visit.
7.6 if it’s for follow-up visits that aren’t related to accidental events.
7.7 if it’s for follow-up visits at a registered medical facility that are related to an accident, but follow-up visits occured 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.)
7.8 if it’s for medical treatment due to illness provided to your child who’s 10 years or younger, but treatment wasn’t provided at a registered casualty facility.
7.9 if it’s for medical treatment due to illness at a registered casualty facility for your child who’s 10 years or younger, but your child didn’t receive after-hours treatment.
(After-hours is Mondays to Fridays between 18:00pm and 07:00am and all-day Saturdays, Sundays and public holidays.)
7.10 if it’s for medical treatment due to illness provided to your child who’s older than 10 years.
7.11 that you didn’t pay from your own pocket, or that your medical aid didn’t pay from your medical savings account.
8. TRAUMA COUNSELLING COVER
When you need to talk to a registered counsellor about specific traumatic events that are affecting you, we’ll cover the consultation fees.
WHAT OUR BENEFIT DOESN’T COVER
We don’t cover coded lines on your healthcare providers’ accounts:
8.1 if you haven’t witnessed, or aren’t directly affected by an act of physical violence or an accident.
8.2 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.
8.3 that you didn’t pay from your own pocket, or that your medical aid didn’t pay from your medical savings account.
8.4 if your counsellors aren’t registered with a recognised South African regulatory body.
9. PREVENTATIVE CARE COVER
We cover the cost of your healthcare providers’ consultation fees and the cost of specific preventative tests and procedures.
WHAT OUR BENEFIT DOESN’T COVER
We don’t cover coded lines on your healthcare or service providers’ accounts:
9.1 if it’s not for consultation fees, preventative tests or procedures that our benefit covers.
9.2 that you didn’t pay from your own pocket, or that your medical aid didn’t pay from your medical savings account.
BENEFITS NOT SUBJECT TO THE OVERALL POLICY LIMIT (OPL)
10. PRIVATE WARD COVER
Don’t want to share a ward next time you’re hospitalised? Use our benefit when your medical aid plan doesn’t provide cover for private ward, lodger, or nursery fees.
WHAT OUR BENEFIT DOESN’T COVER
We don’t cover coded lines on your service providers’ accounts:
10.1 if your medical aid paid it as an exception to the rule.
10.2 if your medical aid partly or fully paid it from a hospital benefit.
10.3 if your medical aid, the hospital or day clinic requires you to be admitted to a private ward due to clinical reasons.
10.4 if the lodger or nursery fees are for someone who’s not covered on your policy.
11. PAYOUT AND WAIVER BENEFITS
11. 1 ACCIDENTAL DISABILITY AND DEATH
We pay a benefit amount in the event of total and permanent disability or death due to an accident.
WHAT OUR BENEFIT DOESN’T COVER
We don’t cover instances:
11.1.1 if total and permanent disability or death isn’t due to an accident.
11.1.2 if it exceeds one claimable event per qualifying person in a benefit year.
11.1.3 if a death certificate or proof of disability isn’t provided, where applicable.
11.2 FIRST-TIME CACNER DIAGNOSIS
When cancer is diagnosed for the first time in your life after you’ve joined us, you’ll receive a payout benefit if the diagnosis meets specific qualifying criteria.
WHAT OUR BENEFIT DOESN’T COVER
We don’t cover:
11.2.1 a cancer diagnosis if it’s not the first cancer diagnosed in your life.
11.2.2 a cancer diagnosis if it’s diagnosed before the first day your cover starts with us, or during a General Waiting Period.
11.2.3 you if pre-cancer cells have been found but a cancer diagnosis hasn’t been confirmed.
11.2.4 cancer of the skin, unless cancerous moles have invaded surrounding or underlying tissue.
11.2.5 a cancer diagnosis if cancerous cells haven’t invaded surrounding or underlying tissue.
11.2.6 Stage 1 breast or prostate cancer.
11.2.7 a cancer diagnosis if it’s diagnosed at age 65 or older.
11.3 MEDICAL AID CONTRIBUTION WAIVER
We’ll pay your monthly medical aid contribution when the contribution payer becomes totally and permanently disabled or passes away.
WHAT OUR BENEFIT DOESN’T COVER
We don’t cover instances:
11.3.1 if the medical aid contribution payer hasn’t become totally and permanently disabled, or hasn’t passed away.
11.3.2 of total and permanent disability, or death of a person who isn’t noted as the medical aid contribution payer.
11.3.3 if a new contribution payer is appointed within 3 months before the claimable event, unless the new contribution payer’s total and permanent disability or death is due to an accident.
11.3.4 if the medical aid contribution payer is a person, registered company, or entity that doesn’t solely fund your medical aid contributions.
11.3.5 where the company or entity is co-owned by two or more Insured Persons registered on your policy, as neither one of you will be regarded a medical aid contribution payer in your individual capacity.
11.3.6 if you’re an employee, and the company or entity pays your medical aid contributions on your behalf which doesn’t form part of your cost to company, you won’t be regarded a medical aid contribution payer.
11.3.7 if medical aid contributions are paid by a trust of which you’re a trust member, but not a trust beneficiary.
11.4 STRATUM POLICY PREMIUM WAIVER
We’ll cover your monthly policy premium when the premium payer is forcibly retrenched, becomes totally and permanently disabled, or passes away.
WHAT OUR BENEFIT DOESN’T COVER
We don’t cover instances:
11.4.1 if the Gap Cover policy premium payer hasn’t been forcibly retrenched, hasn’t become totally and permanently disabled, or hasn’t passed away.
11.4.2 of forced retrenchment, total and permanent disability, or death of a person who isn’t noted as the Gap Cover policy premium payer.
11.4.3 if a new Gap Cover policy premium payer is appointed within 3 months before the claimable event, unless the new premium payer’s total and permanent disability or death is due to an accident.
11.4.4 if the Gap Cover policy premium payer is a person, registered company, or entity that doesn’t solely fund your policy premiums.
11.4.5 where the company or entity is co-owned by two or more Insured Persons registered on your policy, as neither one of you will be regarded a Gap Cover policy premium payer in your individual capacity.
11.4.6 if you’re an employee, and the company or entity pays your Gap Cover policy premiums on your behalf which doesn’t form part of your cost to company, you won’t be regarded a premium payer.
11.4.7 if Gap Cover policy premiums are paid by a trust of which you’re a trust member, but not a trust beneficiary.
12. ACCESS COVER
Need a medical procedure that your medical aid plan excludes from cover? We’ll cover all your related healthcare and service providers’ accounts if your medical procedure is listed as one of the medical events that our benefit covers.
WHAT OUR BENEFIT DOESN’T COVER
We don’t cover coded lines on your healthcare or service providers’ accounts:
12.1 if your medical aid paid it as an exception to the rule.
12.2 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.)
12.3 if it’s for medical procedures or treatments that your medical aid plan doesn’t exclude from cover.
12.4 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.
12.5 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:
12.5.1 arthroscopic surgery;
12.5.2 back or neck surgery;
12.5.3 bunion surgery;
12.5.4 cochlear implant, auditory brain implant and internal nerve stimulator surgery (including the procedure, device, processor and hearing aids);
12.5.5 dental procedures for impacted teeth for children younger than 18;
12.5.6 endoscopic procedures;
12.5.7 functional nasal surgery;
12.5.8 joint replacement surgery (including non-PMB joint replacements and internal prosthetic devices);
12.5.9 knee or shoulder surgery;
12.5.10 non-cancerous breast conditions (including breast reconstruction of a breast not affected by cancer);
12.5.11 oesophageal reflux and hiatus hernia surgery;
12.5.12 removal of varicose veins; or
12.5.13 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.)
GENERAL EXCLUSIONS
We don’t cover healthcare or service providers’ accounts related to any medical procedure, treatment, hospitalisation, illness, disease, loss, damage, death, bodily injury or liability for:
- events that occurred when you weren’t an insured person.
- events that occur during a policy waiting period, unless it’s for accidental events.
- events where your policy’s overall policy limit or a benefit limit has been reached.
- amounts that exceed the additional 300% or 500% cover that your policy provides.
- events where your policy doesn’t provide the right benefit to claim from.
- events that could qualify for more than one benefit provided by your policy, but because the initial medical event’s been assessed and registered under a specific key benefit, any related treatment as a result of the initial medical event, or events that follow the initial medical event won’t be considered under another benefit.
- claims that we’ve 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.
- events where you didn’t obtain pre-authorisation from your medical aid, or where you didn’t follow your medical aid’s rules.
- maxillofacial surgery and related medical conditions or procedures, unless it’s related to accidental injury or cancer.
- prescription medication that you collect at a pharmacy or medication that’s given to you to take home, unless your policy has a benefit that covers it.
- external prostheses, like artificial limbs.
- external medical items, like crutches and birthing pools.
- mechanical or computerised devices, like ventilators, unless your policy has a benefit that covers it.
- co-payments related to robotic surgery, unless your policy has a benefit that covers it.
- artificial insemination, infertility treatment, procedures or contraceptives, unless you’re claiming for tubal ligation, a vasectomy, or a contraceptive device implant if your policy has a benefit that covers it.
- obesity and bariatric surgery.
- reconstructive cosmetic surgery.
- a breast reconstruction if it’s not the first breast reconstruction in your lifetime.
(A breast reconstruction can be an implant or removal of a breast implant.)
- 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.
- mood disorders, emotional and psychological illnesses, unless you’re claiming for counselling under our Trauma Counselling Cover Benefit.
- sleeping disorders.
- stem cell harvesting or treatment.
- costs related to medical reports.
- claims where we’ve negotiated discounts with your healthcare and service providers and paid them in full.
- claims that are resubmitted due to your healthcare or service provider increasing their fees which results in additional shortfalls, but your claim has already been finalised by us.
- information that you didn’t tell us about that can affect the assessment or acceptance of risk.
- events that are covered by more than one Gap Cover insurer.
- 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.
- transport charges and healthcare services that’s provided to you while being transported in an emergency vehicle, vessel, or aircraft.
- 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.
- attempted suicide or intentional self-injury.
- deliberate exposure to exceptional danger, unless you attempt to save a human life.
- events where the use of drugs or alcohol is involved.
- riots, wars, political acts, public disorder, terrorism, civil commotions, labour disturbances, strikes, lock-out or any attempt to such acts.
- active military, police or police reservist activities while you are on active duty.
- 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.
- 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.
