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Gap-Lite Cover

For the younger generation.

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Key Benefits

OAL per beneficiary per annum:
R201 000

in-hospital gap benefits
In-Hospital Benefits

Gap Cover
Co-payments and Co-payments charged as a Percentage
Penalty Fee Cover
Day Hospital/Clinic and/or In Room Surgical Procedures Cover
Prescribed Minimum Benefit (PMB) Cover

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value added benefits
Value Added Benefits

Sira-Go’ Baby
Sirago MedCare (Free Medical Scheme Alternative Dispute Resolution Service (ADR))

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

Emergency Room Cover

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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 250% above scheme rate to a maximum of 350% or at the stated benefit value. 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. We pay up to a sub-limit of R25 000 per policy, and up to
R7 500 per claim. 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 R5 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.

Out-of-hospital Benefits

Emergency Room Cover

There is a sub-limit of R4 500 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
This benefit is applicable to children 8 years and younger who require emergency treatment for illness out of normal consultation hours or treatment that can only be done in an emergency room. All costs related to the event will be covered, whether you are liable to pay the costs from your own pocket or your medical scheme pays it from your savings account.

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.

Value Added Benefits

Sira-Go’ Baby

Sirago will pay out a lump sum of R1 500 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 to changes@sirago.co.za together with your baby’s birth certificate.

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

With this benefit, the policyholder will get access to MedCare’s free ADR service for all disputed PMB claims exceeding R9 000. Policyholders 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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