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086 111 3499

Gap Cover & Health Insurance for Real People

DAY-TO-DAY, EMERGENCY & ACCIDENT BENEFIT OPTION

The variety of benefits we provide could be mistaken for a shopping list!

From unlimited GP and nurse visits, specialist visits, medication, dental and eye care benefits, to wellness assessments and preventative vaccinations and tests.  GET COVER’D!

 

WHY CHOOSE ESSENTIAL PRIMARY PLUS?

It is our health insurance offering that provides essential healthcare solutions to individuals and families. Choose between our Day-to-Day Benefit Option, Emergency and Accident Benefit Option or our Day-to-Day, Emergency and Accident Benefit Option.

Our options complement your medical aid cover, or it can be taken as your primary health cover if you don’t have medical aid cover. Our options are subject to open enrolment, community rating and cross-subsidisation.

WHAT DOES OPEN ENROLMENT, COMMUNITY RATING AND CROSS-SUBSIDISATION MEAN?

Open enrolment means cover is available to everyone. Community rating means we do not discriminate against individuals based on factors such as race and gender. Cross-subsidisation means that all premiums paid by our clients are paid into one risk pool where all claims are paid from.

WHO DO WE COVER?

We cover only you if you choose to join as an individual.

If you join as a family, we cover you, your spouse and any child dependant of whom you are the parent or legal guardian.

MONTHLY PREMIUM

As an individual aged 56 or older you will pay a higher premium from the first day of cover, unless you can submit proof of medical aid or primary healthcare insurance cover for 15 or more consecutive years from the age of 35 onward.

Children aged 20 years or younger pay child dependant premiums. Children aged 21 years or older pay adult dependant premiums if they are full-time students and proof of financial dependency is submitted every year.

We accept proof from the educational facility or stamped copies of your child’s bank account statements of the past 3 months.

ENTRY AGE PRINCIPAL INSURED SPOUSE ADULT DEPENDANT CHILD DEPENDANT
55 or younger R 470 R 335 R 335 R 130
56 or older R 671 R 536

DAY-TO-DAY COVER

Through a national network of providers who have contracted with Unity Health, our health insurance administrator, you have access to more than 2 700 GP’s, 2 700 optometrists and various pharmacies, pathologists and radiologists.

Need help in finding your nearest provider?

Visit www.unityhealth.co.za , contact us for assistance or download our mobile app. Haven’t downloaded our app yet? Click here for a step-by-step guide.

GP CONSULTATIONS AND MEDICAL PROCEDURES

PRE-AUTHORISATION IS REQUIRED FOR 10 OR MORE COMBINED GP OR NURSE VISITS PER PERSON PER YEAR.

This benefit provides unlimited GP consultations at any of our network GP’s.

We cover basic medical and/or surgical procedures that your network GP performs in their rooms, such as stitching of a wound, according to a list of approved tariff codes.

ACUTE MEDICATION

DISPENSING NETWORK GP

When you need medication for an every-day illness, such as a chest infection or flu, your dispensing network GP can provide medication from a formulary list during one of your visits.

There is no benefit limit on acute medication that you receive in the rooms.

NON-DISPENSING NETWORK GP

When your network GP does not dispense medication from the rooms, you will be given a prescription for medication prescribed from a formulary list. You can collect your medication from any Mediscor pharmacy, such as Clicks, Dis-Chem or Pick n Pay.

There is no benefit limit on acute medication that is prescribed by your non-dispensing network GP.

CHRONIC MEDICATION

We cover chronic medication that your network GP prescribes from a formulary for the following 8 chronic conditions and/or diseases:

  • asthma;
  • chronic obstructive pulmonary disorder;
  • diabetes type 1 & 2;
  • epilepsy;
  • hyperlipidaemia;
  • hypertension;
  • HIV/AIDS; and/or
  • tuberculosis.

    BLOOD TESTS AND X-RAYS

    Blood tests, such as a cholesterol or glucose test or x-rays, such as a chest x-ray, are covered when your network GP refers you to the nearest Ampath, Lancet or PathCare pathology facility and/or radiology facility during one of your visits.

    Blood tests and x-rays are covered according to a list of approved tariff codes.

    NURSE CONSULTATIONS

    PRE-AUTHORISATION IS REQUIRED FOR 10 OR MORE COMBINED NURSE OR GP VISITS PER PERSON PER YEAR.

    Visit the on-site nurse at your nearest Clicks, Dis-Chem or Pick n Pay clinic for unlimited consultations for minor illnesses. Your local nurse can prescribe medication for up to Schedule 2 medication.

    SPECIALIST CONSULTATIONS

    PRE-AUTHORISATION IS REQUIRED

    Your network GP must refer you when you need to see a specialist. We will refund up to R 1 200 per consultation to a maximum of R 2 500 per family per year.

    DENTAL CARE

    PRE-AUTHORISATION IS REQUIRED

    Visit any dentist of your choice when you need basic dental procedures, such as fillings or extractions, or emergency dental treatment for an abscess or root canal.

    We also cover urgent dental treatment when an accident causes you to lose a tooth or multiple teeth or causes damage to your teeth.

    All dental procedures are covered according to an approved list of tariff codes, limited to R 1 200 per person per event.

    Specialised dentistry such as bridgework, crowns, dentures and orthodontic treatment are not covered.

    EYE CARE

    Our eye care benefits are provided through PPN, the largest optical network in the country. To find your nearest provider, visit www.ppn.co.za.

    We cover you for:

    • 1 eye test per person every year;
    • 1 standard frame to the value of R 254 per person every 2 years; and/or
    • 1 pair of clear, standard spectacle lenses per person every 2 years.

     We do not cover optional extras, such as tinting or scratch resistant coatings.

    PRE-BIRTH CONSULTATIONS

    PRE-AUTHORISATION IS REQUIRED

    We will refund you, the soon-to-be-mom, for the cost of 2 maternity check-ups and 2 ultrasound scans per person per pregnancy per year at any gynaecologist of your choice, limited to R 3 000 per family per year.

    Ask your network GP about having your scans done in the rooms, subject to the benefit limit provided by our PRE-BIRTH CONSULTATION BENEFIT.

    EMERGENCY AND ACCIDENT COVER

    You are covered for emergencies and accidents at your nearest private hospital and the hospital’s casualty facility.

    We do not cover planned medical procedures, such as childbirth or having cataracts removed.

    OVERALL POLICY LIMIT (OPL)

    There is no Overall Policy Limit (OPL) on our Emergency and Accident Benefits but benefit limits apply as indicated.

    HOSPITAL CARE

    EMERGENCY COVER

    PRE-AUTHORISATION IS REQUIRED

    We will cover the cost to transport you to your nearest private hospital and the cost of stabilisation in the hospital’s emergency unit when you are admitted as an in-patient for a medical emergency, limited to R 22 000 per person per event.

    We do not cover medical procedures that you need after being admitted to hospital for stabilisation, such as a heart bypass. If you need further treatment after stabilisation, we will cover the cost to transfer you to a public hospital and any costs thereafter will be your responsibility.

    WE DEFINE MEDICAL EMERGENCIES AS…

    unexpected events or health conditions, such as a heart attack or stroke, that can result in serious bodily impairment and/or death if you do not receive immediate treatment.

    ACCIDENT COVER

    PRE-AUTHORISATION IS REQUIRED

    You are covered at the nearest private hospital when you need medical treatment for physical injuries caused by accidental events, such as injuries from a motor vehicle accident.

    We will cover your hospital and all related healthcare providers’ accounts during your stay in hospital, limited to R 1 100 000 per person per event.

    WE DEFINE ACCIDENTAL EVENTS AS…

    events where immediate medical treatment is required as a result of a physical injury caused by physical impact, such as a motor vehicle accident.

    CASUALTY VISITS

    PRE-AUTHORISATION IS REQUIRED

    Medical treatment for a physical injury caused by a minor accidental event is covered at your nearest private hospital’s casualty facility, limited to R 6 000 per person per event.

    MRI AND CT SCANS

    PRE-AUTHORISATION IS REQUIRED

    When you are admitted to hospital as a result of an injury caused by an accident, the cost of your MRI or CT scan will be covered limited to R 16 000 per person per year. 

    PHYSICAL REHABILITATION CARE

    PRE-AUTHORISATION IS REQUIRED

    We cover the cost of your physiotherapist and/or occupational therapist when you need physical therapy for an injury caused by an accident for which you have been admitted to hospital.

    You must receive therapy and/or treatment within 3 months from the date that you are discharged from hospital, limited to R 3 000 per person per year.

    24-HOUR MEDICAL EMERGENCY SERVICES

    Our 24-hour national emergency contact centre can assist with the following services in the event of a medical emergency:

    • ambulance transfers between hospitals;
    • emergency transport services by air or road;
    • repatriation of a loved one’s mortal remains within the borders of South Africa, limited to R 7 500 per policy per year;
    • telephonic medical advice.

    PAYOUT BENEFIT

    ACCIDENTAL DEATH

    We cover you and/or your registered spouse in the event of your and/or your spouse’s death due to an accident, limited to a benefit amount of R 10 000 per person, which will be paid out to your nominated beneficiary.

    WELLNESS BENEFIT

    Visit your nearest Clicks, Dis-Chem or Pick n Pay clinic for your wellness assessment, preventative vaccination and/or test.

    WELLNESS ASSESSMENT

    You are covered for 1 wellness assessment per person per year which includes the following health checks:

    • blood pressure;  
    • body mass index;     
    •  cholesterol;
    • glucose levels;
    • waist circumference; and/or
    • HIV/AIDS, which includes counselling before and after testing.

    PREVENTATIVE CARE

    The following preventative vaccinations and/or tests are covered:

    • 1 flu vaccination per person per year to be administered by the 31st of May;
    • 1 pap smear for every female aged 21 years or older every 3 years. You can also ask your network GP about having this procedure done in the rooms during one of your visits;
    • 1 pneumococcal vaccination every 5 years for individuals 60 years or older and /or individuals with a medically proven compromised immune system;
    • 1 prostate specific antigen screening for every male aged 50 years or older every 2 years;
    • 1 tetanus vaccination per person every 10 years; and/or
    • 1 hepatitis A and B vaccination per person once during the lifetime of the policy.

    ESSENTIAL ASSISTANCE PROGRAMME (EAP)

    Our wellness partner, Reality Wellness Group, offers unlimited 24/7 telephonic advice and counselling services for:

    • financial advice;
    • legal advice;
    • HIV/AIDS counselling; and/or
    • trauma counselling.

     We do not cover personal face-to-face counselling.

    WAITING PERIODS

    Waiting periods apply from the start date of the policy and from each insured person’s cover start date unless otherwise specified in your Cover Letter, which you will receive when your cover is activated.

    DAY-TO-DAY, EMERGENCY & ACCIDENT BENEFIT OPTION

    2 MONTH GENERAL WAITING PERIOD

    Cover does not apply to our DAY-TO-DAY, WELLNESS ASSESSMENT and PREVENTATIVE CARE BENEFITS during the first 2 months of cover.

    9 MONTH PRE-BIRTH CONSULTATION WAITING PERIOD
    12 MONTH CHRONIC MEDICATION WAITING PERIOD
    12 MONTH EYE CARE WAITING PERIOD

    EXCEPTION TO THE RULE

    Waiting periods do not apply to our EMERGENCY AND ACCIDENT BENEFITS and ESSENTIAL ASSISTANCE PROGRAMME (EAP).

    *LIFESTYLE BENEFIT

    Our Lifestyle Benefit is offered at no cost to you.

    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.

    *T’S & C’S, BENEFIT AND GENERAL EXCLUSIONS

    View the policy and benefit exclusions that apply to our DAY-TO-DAY, EMERGENCY & ACCIDENT BENEFIT OPTION.

    Read more about the T’s & C’s applicable to our Lifestyle Benefit and how to register.

    This Health Insurance 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.

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