Sirago Underwriting Managers

What is Gap Cover

Gap Cover is the invaluable safety net that covers the shortfall between what medical schemes pay and what specialist doctors charge. Without this, policyholders may find themselves paying for unexpected costs from their own pockets.


Who is covered by this policy?

We cover policyholders and beneficiaries of all ages. The benchmark for premium determination is based on whether you join as an individual, or as a family, and the prospective policyholder’s age at the inception of the policy according to the following three age bands:

  • 54 years and younger
  • 55 years to 64 years
  • 65 years or older

We will provide Gap Cover for you and all the dependants registered on your medical scheme on one policy. If you belong to different medical schemes, or medical scheme options, we will cover two adults (ie the policyholder and on other adult dependant, if applicable) and all child dependants on one policy.

A child is considered to be a child dependant up to the age of 21, however cover can be extended to the age of 27 for full-time students. Documented proof of fulltime studies is required to verify a dependant over the age of 21, or by providing the Certificate of Membership from your medical scheme confirming that the dependant is still on the same medical scheme.

Benefit category descriptions

An event that occurs unintentionally and usually results in harm, injury, damage or loss. Policy cover only extends to accidents occurring after inception of the policy.

An instrument or device designed for a particular medical use.

The fixed amount you have to pay in terms of your medical scheme rules when you are admitted to hospital as an in-patient.

Diseases in which abnormal cells divide without control and are able to invade other tissues. This definition includes leukaemia, lymphoma and Hodgkin’s disease but specifically excludes benign, pre-cancerous/in-situ tumours or growths, as well as all stage zero cancer diagnoses. Any cancer that is diagnosed and treated through primary biopsy and not requiring additional intervention such as radiation therapy, or chemotherapy, shall not be deemed as cancer and will not have any benefit paid. Cover under cancer benefits will not be available for the first 12 months for any person diagnosed with cancer prior to the inception of this policy. Initial Diagnosis: The very first clinically confirmed diagnosis of any form of malignant cancer*, specifically excluding preliminary, tentative or other diagnosis not supported by clinical evidence of malignancy. This benefit excludes any incidence of cancer/pre-cancer prior to inception of the policy.

*Malignant Cancer: refers to cancer cells that can invade and kill nearby tissue and spread to other parts of the body. This definition excludes any diagnosis related to skin cancer.

The fixed amount excess imposed in terms of your medical scheme rules for undergoing a specific procedure whether in or out of hospital. This will include, for example MRI scans, CT scans, ultrasound scans, and scopes.

A disease or period of sickness affecting the body, which warrants treatment at an emergency facility, however restricted to beneficiaries under the age of 8 years old.

A serious situation or occurrence that happens unexpectedly and demands immediate medical attention in an Emergency Room.

Covers the difference between the medical scheme rate and the rate that service providers charge.

A premium waiver benefit is claimable for the surviving spouse/adult dependent of the current Sirago policy in the event of death or total permanent disability of the policyholder (irrespective of source of premium) on the Sirago policy.

The amount claimable on the medical statement, not covered by your medical scheme up to a specified limit.

A disease or period of sickness affecting the body, which warrants treatment at an emergency facility.

A procedure in a surgical suite that meets the requirements of a restricted area, and which is designated and equipped for performing surgical operations, or other invasive procedures that require an aseptic field which would/could ordinarily be undertaken in an acute facility.

Only in event of death and/or total permanent disability of the policyholder, will we contribute towards your medical scheme payments, provided the medical scheme membership is active for a 6 month period. See benefit description.

The amount you have to pay in terms of your medical scheme rules when you are admitted to a hospital that is not a designated service provider as provided for in your medical scheme rules.

A set of benefits as defined in the Medical Scheme Act and Regulations which ensures that all scheme members have access to certain minimum health benefits, regardless of your medical scheme option. This includes a requirement for medical schemes to pay the full cost of diagnosis and treatment for a list of medical conditions.

The Gap portion claimable for the difference between the medical scheme rate and the charged amount for preventive care treatment which is the care you receive to prevent illnesses or diseases.

The Gap portion claimable for the difference between the medical scheme rate and the charged amount for the listed set of primary care consultations applicable per option.

The Gap portion claimable for the difference between the medical scheme rate and the charged amount for the in-room consultation fee as charged by a specialist doctor, applicable per option.

This benefit covers the shortfall on a limitation applied in terms of your medical scheme benefits for internal prosthesis, MRI scans and CT scans on the amount of coverage available to cover a specific stated benefit within this insurance policy. It places a maximum on the amount available, rather than providing additional coverage.

Individuals who require on going treatment for rehabilitation purposes.

Trauma is defined as an experience triggered by a sudden, external overwhelming event or persistent overwhelming conditions in which one’s ability to cope is compromised, as one experiences a real or perceived threat to his/her life, bodily integrity, or that of a significant other. Trauma Counselling is the structured and problem-oriented treatment and/or intervention the affected individual receives from a registered medical professional to address these internal processes. This benefit covers you for, but is not limited to; dread disease, hijacking and/or violent crimes at the discretion of the insurer, on the provision of supporting documentation.

What are our waiting periods?

A “Waiting Period” is a defined period of time in which a policyholder may not claim any or may only claim certain policy benefits imposed by Sirago.

General Waiting Periods

A 3 month general waiting period is applicable on any newly incepted policies and/or additional dependants to the current policy, except in the event of an accident.

In the event that the policyholder has held a Sirago policy for 12 months without a break in cover and wants to upgrade to a higher option, all additional benefits will be subject to a 3 month waiting period.

If the policyholder has held a Sirago policy for less than 12 months and intends to upgrade to a higher option, the balance of the relevant waiting periods in the higher option per benefit category are applicable.

A 10 month waiting period on pre-existing conditions, diseases or illness.

Specific Waiting Periods Applicable to Certain Procedures (On Gap Policies Only)

The following conditions are excluded within the first 6 months of the policy cover inception:
Myringotomy and grommets;
Hysterectomy (except where malignancy can be proven);
Spinal, back, neck and joint related procedures (repairs, scopes, joint replacement) except in the case of an accident. This includes treatments related to any and/or investigations including MRI scans, CT scans and scopes.

Thereafter, benefits will be payable at a rate of:
50% of benefits available from month 7 to 10.
From month 11, the policy benefits will be fully available except where there are condition-specific exclusions and when a new beneficiary joins the policy, and is subject to underwriting terms.

Specific Waiting Periods applicable to certain benefit categories and certain conditions and/or relevant options:
10 month waiting period for pregnancy and confinement.
Accidental Death, Total Permanent Disability and Premium Waivers are subject to a 6 month waiting period.
Initial Cancer Diagnosis is subject to a 3 month waiting period.
A 12 month waiting period on all pre-existing cancer related treatments.

Summary of Policy Terms and Conditions

No benefits are payable for:

  • Any claims not authorised by your medical scheme, unless it’s part of the benefit entitlement
  • Claims that exceed the utilisation or benefit limit per annum
  • Out-patient treatment other than defined
  • Any and all experimental treatments and medication both in-and out-of-hospital
  • An event not covered that falls outside of the policy’s intention
  • Any pre-existing condition, disease, disorder or illness, for 10 months
  • Any pre-existing cancer condition, disease, disorder or illness, for 12 months
  • Claims for regular or routine medical treatment of a diagnostic nature
  • Illness or injury resulting from alcohol or drug abuse
  • Any psychiatric or psychological condition
  • Suicide or attempted suicide
  • Medication, drugs, prescriptions, consumables and equipment used, unless it forms part of the benefit entitlement
  • Cosmetic surgery unless defined as part of the benefit entitlement of this policy
  • Elective procedures
  • Diagnostic investigations, treatment or surgery related to eating disorders, obesity or weight management
  • Investigations, treatment, medication or surgery related to any condition where the policyholder seeks advice, diagnosis and/or treatment outside the borders of South Africa
  • Body Mass Index (BMI), unless defined as part of the benefit entitlement of this policy
  • Diagnostic Investigations, treatment or surgery relating to any form of assisted reproduction
  • Participation in any form of race or speed test involving mechanically propelled vehicles or crafts, participation as a professional sports person or any hobby defined as dangerous in the policy terms and conditions

No benefits will be paid for claims arising from

  • Participation in war, invasion, acts of a foreign enemy, hostilities, civil war, rebellion, revolution, insurrection or political risk of any kind, terrorism or violence
  • Any riot, strike, public or domestic disorder, civil commotion, labour disturbances or lock-out
  • Active military duty, police duty, police reservist duty, civil commotion, labour disturbances, riot, strike or the activities of locked out workers
  • Preventing authorities from dealing or controlling any of the above activities
  • Compensation in terms of the War Damage Insurance Act 85 of 1976
  • Nuclear weapons, nuclear material or ionizing radiation
  • Committing unlawful activities in the Republic of South Africa
  • Loss arising from any contractual liability
  • Consequential loss or damage

The above is a summary of the terms and conditions, for a complete list please refer to the policy wording which forms part of your Schedule of Insurance.

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