It is our middle of the range option that provides cover for the most likely medical expense shortfalls that you may experience on doctors’ and specialists’ private fees and co-payments.
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.
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 person per year applies across all benefits, except when you claim from our Accidental Disability and Death and First-Time Cancer Diagnosis Benefits, as these benefits are offered over and above the benefits that form part of the OPL.
Our benefit provides an additional 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.
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;
- 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.
ADMISSION AND PROCEDURE CO-PAYMENTS
This benefit refunds the co-payments or deductibles that your medical aid requires you to pay before undergoing certain medical procedures and/or diagnostic services, such as MRI/CT scans and scopes, limited to R 50 000 per policy per year.
10 MONTH BENEFIT RULE
If you claim from our GAP COVER and/or CO-PAYMENT COVER within the first 10 months of cover for a medical event related to:
- cardiovascular procedures;
- cataract removal;
- 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.
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 8 000 per policy per year.
TRAUMA COUNSELLING COVER
We cover the cost of your registered counsellor’s consultation fees when you:
- witness, or are directly affected by an act of physical violence or an accident;
- receive news of a loved one’s or of your own diagnosis of a critical illness; and/or
- mourn the death of a loved one.
You will be refunded for 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 7 000 per policy per year.
(Not subject to the OPL)
ACCIDENTAL DISABILITY AND DEATH
We cover you and/or your spouse for a benefit amount of R 7 000 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.
FIRST-TIME CANCER DIAGNOSIS
We pay a benefit amount of R 5 000 per person per lifetime when cancer is diagnosed for the first time in your life, *subject to specific qualifying criteria.
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.
Our Lifestyle Benefits are offered at no cost to you.
Fill up at any SHELL service station and get rewarded with 22 cents per litre of diesel and 15 cents per litre of petrol. Rebates are subject to change.
INTERNATIONAL TRAVEL INSURANCE
We cover acute illness and/or injury when you travel outside of South African borders. Whether you travel alone, or together with your dependants registered on your Gap Cover policy, our benefit is limited to 1 trip per policy per year to a maximum of 31 days, *subject to specific qualifying criteria.
*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.