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086 111 3499

Gap Cover & Health Insurance for Real People

WHY CHOOSE ACCESS OPTIMISER PLUS?

It is our booster option that covers specific medical procedures and events that your medical aid plan excludes from cover, as well as provide cover for the most likely medical expense shortfalls that you may experience on doctors’ and specialists’ private fees.

 

WHO DO WE COVER?

We cover individuals and families.

Our family options cover you, your spouse and all the dependants registered on both your and your spouse’s medical aid plans.

MONTHLY PREMIUM

A standard monthly premium applies regardless of whether you join as an individual or whether you and all your dependants join.

As an individual aged 65 or older, you will be covered 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.

OVERALL POLICY LIMIT (OPL)

An Overall Policy Limit (OPL) of R 165 000 per policy per year applies regardless of whether you are covered as an individual or a family. Our Accidental Disability and Death Benefit is not subject to the OPL as this benefit is offered over and above the benefits that form part of the OPL.

KEY BENEFITS

ACCESS COVER

We cover the cost of the hospital or day clinic and all your related healthcare providers’ accounts when you need one of the below listed medical procedures and/or treatments that your medical aid plan excludes from cover, limited to the rand amounts as indicated per policy per year:

MEDICAL PROCEDURE/EVENT NOT COVERED BY YOUR MEDICAL AID ACCESS COVER PROVIDES
Arthroscopic surgery R 50 000
Back and/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

MEDICAL PROCEDURE/EVENT NOT COVERED BY YOUR MEDICAL AID

ACCESS COVER PROVIDES

Functional nasal surgery

R 23 000

Joint replacement surgery

R 50 000

Knee and/or shoulder surgery

R 25 000

MRI and/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 and/or lipomas)

R 20 000

YOUR NEXT STEP

  • When your healthcare provider informs you that you need a medical procedure or treatment that forms part of the list of procedures and/or treatments that we cover, you will be required to obtain cost estimates from your preferred hospital or day clinic and all related healthcare providers.
  • We will issue a guarantee of payment as an undertaking to pay your service and/or healthcare providers directly once your claim is approved.

ACCESS COVER 10 MONTH BENEFIT RULE

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

  • arthroscopic surgery;
  • back and/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;
  • knee and/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; and/or
  • skin disorders (including benign growths and/or lipomas), 

we will cover only 20% of the approved claim amount, subject to the benefit  limits.

If, however, your medical event is due to a medical condition that you received advice and/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 do not form part of this Benefit Rule and are never subject to any waiting periods.

GAP COVER

Our ACCESS COVER benefit covers specific medical procedures and/or treatments that your medical aid plan excludes from cover.

Our GAP COVER benefit provides an additional 200% or 500% cover above your medical aid plan’s rate to cover the difference between what your healthcare providers charge and the rate your medical aid pays from a hospital or risk benefit for medical procedures and/or treatments that are not excluded from cover.

We cover the shortfalls on medical procedures performed by your doctor and specialist that your medical aid does not cover in full, as well as shortfalls related to:

  • consumable items, such as surgical gloves, and medication received during your medical event;
  • dental related procedures:
    • such as wisdom teeth extractions, limited to R 4 000 per policy per year;
    • for accidental injury or cancer treatment, limited to R 8 000 per policy per year;
  • pathology;
  • physiotherapy;
  • Prescribed Minimum Benefit (PMB) medical procedures;
  • radiology, which includes:
    • basic radiology, such as black and white x-rays; and/or
    • specialised radiology, limited to R 5 000 per policy per year.

GAP COVER 10 MONTH BENEFIT RULE

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); and/or
  • hysterectomy (full cover applies if required due to cancer when diagnosed after the General Waiting Period),

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

If, however, your medical event is due to a medical condition that you received advice and/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 do not form part of this Benefit Rule and are never subject to waiting periods.

CASUALTY COVER

This benefit covers the cost of a casualty event, including all related healthcare services provided at a registered medical facility when you need immediate treatment due to an accident.

We also cover your child dependant younger than 6 at a registered casualty facility when they are ill and need after-hours medical treatment. 

WHEN IS AFTER- HOURS?

After-hours is Mondays to Fridays between 18:00pm and 07:00am and all-day Saturdays, Sundays and public holidays.

We will 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, limited to R 2 000 per policy per year.

PAYOUT BENEFIT

(Not subject to the OPL)

ACCIDENTAL DISABILITY AND DEATH

We cover you and/or your spouse for a benefit amount of R 5 000 each in the event of your and/or your spouse’s total and permanent disability or death due to an accident, limited to 1 event per person per year.

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.

3 MONTH GENERAL WAITING PERIOD

Cover does not apply during this period unless you claim for accidental events that occur after your cover start date.

12 MONTH PRE-EXISTING CONDITION WAITING PERIOD

Cover does not apply during this period for investigations, medical procedures, surgeries and/or treatments related to any illness and/or medical condition that was diagnosed and/ or for which advice and/or treatment was received within 12 months before your cover start date.

*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 qualifying criteria that apply to our First-Time Cancer Diagnosis Benefit and see our policy and benefit exclusions.

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

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.