Sirago Underwriting Managers

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Gap Assist Cover

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Key Benefits

OAL per beneficiary per annum:
R213 000

in-hospital gap benefits
In-Hospital Benefits

Gap Cover
Robotic Surgery
Co-payments and Co-payments Charged as a Percentage
Penalty Fee Co-payment
Day Hospital/Clinic and/or In Room Surgical
Prescribed Minimum Benefit (PMB) Cover
Hospital Account Shortfalls

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cancer benefits
Cancer Benefits

Cancer Co-payment Benefit
Cancer Benefit - Boost

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out-of-hospital gap benefits
Out-of-hospital Benefits

Casualty Benefit
Appliance Benefit
Trauma Counselling

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value added benefits
Value Added Benefits

Gap Cover Premium Waiver
Sira’Go Baby
Sirago MedCare (Free Medical Scheme Alternative Dispute Resolution Service (ADR))

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In-hospital Benefits

Gap Cover

This covers the difference (the shortfall or the gap) between what the medical scheme pays and the doctors and specialists charge in hospital. We settle claims at up to 500% above scheme rate to a maximum of 600% or at the stated benefit value. For Robotic surgery claims that are reflected on the hospital account, we will cover up to a sub-limit of R12 000 per claim, maximum of 1 claim per policy

Co-payments and Co-payments Charged as a Percentage

Co-payment cover is for the co-payments (including co-payments expressed as a percentage), excesses, or deductibles as stipulated, or imposed by a medical scheme, for specified procedures, cover for hospital admission fees, or surgical procedures. The co-payment must be part of your medical scheme rules which will be highlighted on the authorisation for your procedure. We pay up to a sub-limit of R13 500 per claim. Subject to the OAL.

Refer to the Cancer Co-payment benefit for claims related to cancer.

Penalty Fee Co-payments 

When you choose to use a hospital that is not on your medical scheme’s network, you may have to pay a stated amount or percentage of the accounts as specified by your medical scheme rules.

This benefit has a sub-limit of R8 000 per claim, limited to 1 claim per policy, irrespective of whether a rand amount or percentage penalty fee is charged by the medical scheme. Note that this is for the voluntary use of a non-designated service provider or network hospital and includes the use of a partial cover network hospital. Co-payments for administration charges are specifically excluded from cover on this option. Subject to the OAL.

Day Hospital/Clinic and/or In Room Surgical Procedures
Cover

This benefit will cover the shortfall for any day hospital, clinic, or in-room procedures including acute hospitals if a policyholder elects to have the treatment that would normally be performed in hospital, done in a day hospital, clinic, or in a doctor’s room by a registered medical professional. Subject to the OAL.

Prescribed Minimum Benefit (PMB) Cover

Prescribed Minimum Benefits (PMB) give all scheme members access to certain minimum health benefits, regardless of your medical scheme option. Medical schemes are required to pay the full cost of diagnosis and treatment of a defined list of PMB medical conditions.

PMB Cover on this policy is only for the shortfalls resulting from the use of a non-designated service provider for a planned PMB procedure. This is not applicable in the event of an emergency. In the event of an emergency, PMB protocols should be adhered to. Subject to the OAL.

Hospital Account Shortfalls

This benefit will cover any charges, like consumables or take-home medication, on the hospital account that the medical scheme has not paid. We also cover take-home medication that the medical scheme has not paid from risk and the cost of upgrading to a private ward up to the benefit amount.

We pay up to R3 000 per policy, and R500 per claim. A R1 000 sub-limit is applicable to private room upgrades. Subject to the OAL.

Out-of-hospital Benefits

Casualty Benefit

There is a sub-limit of R8 000 for all Emergency Room Cover. This benefit covers an emergency at any registered emergency room, hospital, or casualty facility when you require immediate medical treatment due to an accident and trauma, or illness. We will cover a general practitioner (GP)’s consultation rooms if no other emergency facility is available within a 30 km radius. Ambulance costs are not covered by this benefit.

ACCIDENT & TRAUMA BENEFIT
All costs related to the accident/trauma event will be covered, whether you are liable to pay the costs out of your own pocket or if your medical scheme pays from your savings.

CHILD EMERGENCY ILLNESS BENEFIT
All costs related to the initial emergency illness event will be covered and paid up to R2 000 per claim of the sub-limit, if you are liable to pay the costs out of your own pocket, or if paid from your medical scheme savings. This is applicable to any beneficiary 12 years and younger who needs emergency treatment outside of normal consultation hours or treatment that can only be done in an emergency facility.

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Out of normal consultation hours means 18h00 to 07h00 on Monday to Friday, and all of Saturday, Sunday, and South African public holidays. Subject to the OAL.

Appliance Benefit

We will pay up to R4 000 per policy, R1 300 per claim for the shortfall between the medical scheme benefit amount (if there is a defined rand limit) and the service provider account for the following appliances: hearing aids, wheelchairs, continuous positive airway pressure (CPAP) machines, humidifiers, insulin pumps, glucometers, nebulisers, and Mirena devices.

Trauma Counselling

This benefit covers trauma counselling with a registered medical professional within the first 6 months after a traumatic event, such as but not limited to dread disease, hijacking, and/ or violent crime. We will pay up to R4 000 per policy.

Cancer Benefits

Cancer Co-payment Benefit

This benefit applies if your medical scheme cancer benefit has been reached and a percentage co-payment is imposed. This benefit incorporates co-payments for ongoing cancer-related treatments and biological drugs. Ongoing treatment must be in line with the registered treatment plan of your medical scheme to access this benefit, up to R22 000 per claim. Subject to the OAL.

Cancer Benefit – Boost

The Cancer Boost Benefit is applicable to policyholders whose medical scheme option has a defined rand limit for cancer treatment and the rand limit on the medical scheme has been reached.

We will cover the costs of ongoing treatment in line with the medical scheme’s registered treatment plan once the rand limit has been reached. Subject to the OAL.

Value Added Benefits

Gap Cover Premium Waiver

In the event of accidental death or total permanent disability of the Sirago policyholder, we will keep the premiums for your policy as a credit for 6 months. This benefit may be claimed by the surviving spouse or adult dependent on the Sirago policy.

Sira’Go Baby

Sirago will pay out a lump sum of R2 000 to you, per newborn baby, when the baby is registered on your gap policy within 90 days of birth.

To register your newborn(s), simply fill out the additional dependant form and submit it to changes@sirago.co.za together with your baby’s birth certificate.

Sirago Medcare – Free Medical Scheme Alternative Dispute Resolution Service (ADR) 

This benefit gives you access to MedCare’s free ADR service for all disputed PMB claims exceeding R9 000. You can also access the MedCare service for all claims less than R9 000, including all potential medical scheme disputes, at a 60%, 20%, and/or 15% discounted rate depending on the required service. Your broker can also access this service on your behalf and will subsequently have access to the MedCare website: siragomedcare.co.za.

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