FREQUENTLY ASKED QUESTIONS

 

 

Are you a medical aid member? Good, because Gap Cover and your medical aid cover go together.

It’s designed to cover the shortfalls that exist when your healthcare provider, like your doctor or specialist, charges more than what your medical aid plan pays.

Your option could have cover for co-payments, shortfalls on internal prosthetic devices, MRI and CT scans, cancer treatment, physical rehabilitation, out-patient specialist consultations, casualty events, trauma counselling and preventative care, to name a few. You could also receive pay-out benefits for accidental disability and death, first-time cancer diagnosis, and waiver benefits that cover your monthly Gap Cover policy premium and medical aid contribution on your behalf when life happens and the premium payer no longer can.

We also give benefits over and above the benefits that are dependent on you being a medical aid member. Ask us about it!

 

WHO CAN I ADD TO MY POLICY?

Your spouse, children, parents, adopted children, foster children… anyone really, as long as they’re registered dependants on your medical aid plan.

Does your spouse belong to a different medical aid plan? No problem, we’ll cover both of you on one Gap Cover policy, including any dependants that may be covered on your spouse’s medical aid plan. We’re  awesome that way.

If your child is financially dependent on you but belong to their own medical aid plan, they can’t be added to your Gap Cover policy. Rule of thumb – if they belong to their own medical aid plan, they must be covered on their own Gap Cover policy.

DOES MY POLICY PREMIUM INCREASE FOR EVERY DEPENDANT I ADD?

Policy premiums don’t increase for every dependant added, but your premium will increase when you’re covered on a single insured policy and move over to a family insured policy.

Let’s explain… if you’re the only person covered on your policy and pay an individual premium your premium will increase when you add a dependant because your policy will upgrade from an individual to a family policy.

 If your policy already covers other family members, then you’re already paying a family premium which won’t increase again when additional dependants are added.

It’s possible that your policy premium will increase when you add a 65+ dependant. Give us a call so that we can explain the ins and outs.

HOW DO I ADD A DEPENDANT TO MY POLICY?

Easy… just pop an email to yoursupport@stratumbenefits.co.za, let us know who we should add and send us an updated medical aid certificate.

CAN DEPENDANTS STAY ON COVER ONLY UP TO A SPECIFIC AGE?

So you’re asking if we’ll kick someone off cover because of their age? Now there’s a thought…

Kidding!          

No ways! As long as the individuals who are registered on your Gap Cover policy are registered on your or  your spouse’s medical aid plan, we’re happy to keep them on cover.

WILL MY DEPENDANTS GET WAITING PERIODS?

All dependants are subject to underwriting but that doesn’t necessarily mean they’ll receive waiting periods.

For example, if you’re the only person covered on your policy and you add a dependant, that dependant will receive the same waiting periods that apply to the policy at the time we add them to your policy.

There are exceptions to the rule for newlyweds and newborns which we’ll gladly explain in more detail. Give us a call!

TELL ME MORE ABOUT OPTION CHANGES…

Upgrading or downgrading? You can chop and change as many times as you’d like.

When you upgrade to a policy that offers enhanced benefits, the enhanced benefits will be subject to a Pre-Existing Condition Waiting Period of up to 12 months… unless there’s a concession where a reduced    waiting period will apply.

Pop an email to yoursupport@stratumbenefits.co.za with you option change request.

I DON’T INTEND TO MISS PAYING A MONTHLY PREMIUM, BUT IF I DO…

When one policy premium is missed, your cover will be suspended. You can manually pay the outstanding premium to avoid a double debit, but this must be paid at least 7 working days before your next debit order deduction date.

If you don’t manually pay the outstanding premium, we’ll double debit your account the following month for two months’ premiums plus a non-refundable admin fee of
R 25.

If this debit order fails, your policy will be cancelled.

A policy will automatically be cancelled when a debit order returns with a bank code that says we have no authority to debit or for deceased estates, amongst others.

I’M GOING FOR A MEDICAL PROCEDURE. WILL SHORTFALLS BE COVERED?

First and foremost, we’re sending good vibes and well wishes your way!

We don’t pre-authorise or pre-assess claims upfront because there’s no way of telling what your doctor or specialist will charge, or what your medical aid will pay.

We need that information to accurately assess shortfalls.

 Give us a call so that we can confirm your benefits and give you typical examples of when, and how our cover works.

CO-PAYMENTS AND SUB-LIMITS… WHAT ARE THESE AND DOES MY GAP COVER POLICY COVER IT?

Co-payments, also known as deductibles, are upfront payments that your medical aid wants you to make before you’re admitted to hospital or before you go for certain medical procedures.

We refund in- and out-of-hospital co-payments and deductibles of any amount or percentage. Have a look to see if your Gap Cover policy has a benefit called CO-PAYMENT COVER.

Sub-limits, or annual limits, are benefits that your medical aid plan provides that are limited to specific rand amounts. For example, a cardiac pacemaker costs R 60 000 but your medical aid plan only covers R 40 000 of the device… the difference of R 20 000 is typically what we’ll cover.

Have a look to see if your Gap Cover policy has a benefit called SUB-LIMIT COVER.

BY WHEN MUST I SUBMIT MY CLAIMS?

Within 6 months from the date your medical event occurred.

We also give you up to 90 days to submit any outstanding documents that we require if we didn’t get everything the first time around.

We assess claims within 7 – 10 working days once all the necessary documents are submitted.

What to submit? For most Gap Cover claims, we need a copy of your medical aid’s claims transaction statement that shows what your healthcare or service provider charged, what your medical aid paid, and from which benefit it was paid.

We also need a copy of your healthcare or service provider’s account, proof of payment – if you’ve made payment directly to the practice – and of course, a fully completed Gap Cover Claim Form. Check out our Basic Guide to Submitting a Claim here.

Email claims to yourclaim@stratumbenefits.co.za or submit it online.

I’VE HEARD THAT GAP COVER COVERS EVERYTHING MY MEDICAL AID PLAN DOESN’T COVER.

We’re good, but regrettably not that good. Insurance like that doesn’t exist.

We believe our Gap Cover options cover what needs to be covered and add value where it’s meant to, but there are benefit and general exclusions. Sorry!

Can’t find the answer to your question? Feel free to give us a call on 010 593 0981, pop an email to yoursupport@stratumbenefits.co.za or send a message on Chat Box and we’ll get back to you right away.

Gap Cover isn’t medical aid cover, doesn’t provide similar cover as that of a medical aid and can’t be substituted for medical aid membership.