WHY CHOOSE ELITE?
It is our premium option that offers the widest range of benefits.
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 Private Ward, Accidental Disability and Death, First-Time Cancer Diagnosis, Medical Aid Contribution Waiver and Stratum Policy Premium Waiver 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 6 000 per policy per year;
- for accidental injury or cancer treatment, limited to R 12 000 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.
ROBOTIC SURGERY CO-PAYMENT
We will refund the co-payment that your medical aid requires you to pay before undergoing robotic surgery, limited to R 10 000 per policy per year.
We will also refund the co-payment that you are required to pay when you make use of a hospital or day clinic outside your medical aid’s preferred network, limited to 1 co-payment of up to R 10 000 per policy per year.
INTERNAL PROSTHETIC DEVICES
Limited to R 30 000 per person per event.
RENAL DIALYSIS TREATMENTS
Limited to R 30 000 per person per event.
COLONOSCOPIES AND GASTROSCOPIES
Limited to R 3 000 per person per event.
MRI AND CT SCANS
We will also cover the difference in cost that you are responsible to pay, or the full amount of a scan when your medical aid plan’s sub-limit or annual limit is reached, limited to R 3 000 per person per event.
10 MONTH BENEFIT RULE
If you claim from our GAP COVER, CO-PAYMENT COVER and/or SUB-LIMIT 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.
PRIVATE WARD COVER
(Not subject to the OPL)
This benefit covers the hospital fees that you are responsible to pay when your medical aid plan does not provide cover for:
- a private ward that you choose to use;
- a lodger fee for your spouse, or any other person who is registered on your Gap Cover policy, who stays with you when you are hospitalised; and/or
- a nursery fee when you are admitted to hospital and are unable to take care of your child dependant who is also registered on your Gap Cover policy.
Limited to R 2 500 per policy per year.
Our Gap Cover benefit covers the difference in cost between what your healthcare providers charge and the rate your medical aid pays from a hospital or risk benefit for a mastectomy and the reconstruction of an affected breast.
Our Breast Reconstruction benefit covers you when you have a breast reconstruction done on an unaffected breast that your medical aid plan excludes from cover, limited to 1 event of up to R 30 000 per person per lifetime, *subject to specific qualifying criteria.
CANCER TREATMENT SHORTFALLS
We cover the difference in cost between what your healthcare providers charge and the rate your medical aid pays from an oncology benefit for healthcare services related to your cancer treatment, including co-payments related to your cancer treatment when the oncology benefit limit your medical aid plan provides is reached.
CANCER TREATMENT TOP-UP
When the oncology benefit limit provided by your medical aid plan is reached, we will cover the cost of your ongoing cancer treatment.
PHYSICAL REHABILITATION TOP-UP COVER
Our benefit covers the cost of admission and therapy in a sub-acute or step-down facility when the rehabilitation benefit your medical aid plan provides is reached and you require ongoing physical rehabilitation treatment due to an accident, limited to R 10 000 per person per year.
OUT-PATIENT SPECIALIST CONSULTATION COVER
Subject to a standard 3 Month General Waiting Period.
We cover the difference in cost between what your specialist charges for a consultation in their private rooms and the rate your medical aid plan applies to out-patient specialist consultation fees.
Your medical aid must pay a portion of your specialist’s consultation fee from a hospital, risk, or day-to-day benefit or from your medical savings account.
Limited to R 1 000 per consultation with a maximum of 3 consultations per policy per year.
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 12 000 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 10 000 per policy per year.
PREVENTATIVE CARE COVER
Our benefit covers the cost of your healthcare provider’s consultation fee and the cost of the following preventative tests and/or procedures:
- contraceptive device implant;
- full blood count;
- pap smear; and/or
- prostate screening.
When you pay an amount from your own pocket or your medical aid pays an amount from a day-to-day benefit or your medical savings account, we will refund the amount to you limited to R 1 000 per policy per year.
PAYOUT AND WAIVER BENEFITS
(Not subject to the OPL)
ACCIDENTAL DISABILITY AND DEATH
We cover you and/or your spouse for a benefit amount of R 25 000 each in the event of your and/or your spouse’s total and permanent disability or death due to an accident.
We also cover your dependants for a benefit amount of R 5 000 each in the event of their 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 30 000 per person per lifetime when cancer is diagnosed for the first time in your life, *subject to specific qualifying criteria.
MEDICAL AID CONTRIBUTION WAIVER
When the person responsible for paying your monthly medical aid plan contributions becomes totally and permanently disabled or passes away, we will continue to pay your monthly contributions up to R 4 500 per month for 6 months.
STRATUM POLICY PREMIUM WAIVER
We will continue to pay your policy premiums for 12 months when the person responsible for paying the monthly premiums is forcibly retrenched, becomes totally and permanently disabled or passes away.
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.
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 Breast Reconstruction and First-Time Cancer Diagnosis Benefits 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.