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 will settle claims up to 350% of the medical scheme rate up to a maximum of 450% 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 R18 000 per policy. Subject to the OAL.
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. Subject to the OAL.
Refer to the Cancer Co-payment benefit for claims related to cancer.
Penalty Fee Cover
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 R11 500 per claim and limited to 1 claim per policy on this option, 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 R4 500 per policy, R950 per claim. A sub-limit of R1 000 is available for private room upgrades. Subject to the OAL.
Sub-limit Enhancer Benefit
This benefit has a sub-limit of up to R26 000 per policy, max R13 000 per claim. Medical scheme benefits available on the medical scheme option for MRI & CT scans, internal prostheses, and Transcatheter Aortic Valve Implantation (TAVI) procedure valves only.
When you exceed your medical scheme benefit limit during the time of the event, resulting in a shortfall or “gap”, we will pay the shortfall up to the claim limit.
If you claim and your medical scheme limit has been reached at the time of the event, meaning it was used up before the claim event, and your medical scheme does not contribute anything towards this benefit, we will also not pay. Subject to the OAL.
