Sirago Underwriting Managers

Gov-Gap

A tailor-made solution for government employees.

What is Gov-Gap Cover

This policy has an Overall Annual Limit (OAL) of R201 000 per beneficiary.

This product is a tailor made solution for Government employees who need to optimise their healthcare cover portfolio and premiums covered by Persal.

Membership Eligibility: Principal policyholders must be in the full-time employment of the State and be in possession of a valid and current Persal number in order for a Gov-Gap policy document to be issued. Gov-Gap has a policy cease age of 65. The policy will cease at the end of the benefit year when the policyholder turns 65.

in-hospital gap benefits
In-Hospital Benefits

Gap Cover
Co-payments
Day Hospital/Clinic and/or In Room Surgical Procedures Cover
PMB Cover
Hospital Account Shortfalls
Sub-limit Enhancer

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cancer benefits
Cancer Benefits

Cancer Boost Benefit

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

Emergency Room Cover
Day-to-day Specialist Consultation Fee

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value added benefits
Value Added Benefits

Gap Cover Premium Waiver
Medical Scheme Premium Waiver
Accidental Death
Cancer Cover (Initial Diagnosis)
Sira-Go’ Baby
Sirago MedCare (Free Medical Scheme Alternative Dispute Resolution Service (ADR))

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In-hospital Benefits

Gap Cover

Gap Cover will settle claims up to 500% above your medical scheme plan/option rate, to a maximum of 600% or at the scheme stated benefit value as determined within your scheme policy.

Co-payments

The excesses imposed by your medical scheme payable to a maximum rand limit for specified procedures or tests. Cover for co-payments imposed by medical schemes for hospital admissions, scans and surgical procedures. Co-payment benefits are subject to a sub-limit of R40 000 per policy per annum, limited to R6 000 per claim.

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

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

Will settle the GAP portion of claims.

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 R6 000 per policy, and R1 500 per claim,
3 claims per beneficiary. Subject to the OAL.

Sub-limit Enhancer

This benefit has a sub-limit of R45 000 per policy, up to R17 500 per claim. Medical scheme benefits available on the medical scheme option for MRI & CT scans, intraocular lenses, 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 depending on the Gap option you are on. 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.

Out-of-hospital Benefits

In-room/Day-to-Day Specialist Consultation Fee

This benefit covers the shortfall on the consultation at a specialist outside of hospital (excluding Psychiatrist and Psychologist) up to R5 000 per policy, and R1 000 per claim. This benefit is only applicable to consultation codes 0190, 0191, and 0192. The medical scheme needs to make at least partial payment towards the consultation code mentioned above. Subject to the OAL.

Emergency Room Cover

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.

ILLNESS BENEFIT
All costs related to the emergency illness event will be covered and paid up to R1 500 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 9 years and older who needs emergency treatment outside of normal consultation hours or treatment that can only be done in an emergency facility.

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.

Cancer Benefits

Cancer Boost Benefit

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

Value Added Benefits (These do not form part of the aggregated OAL of R201 000)

Gap Cover

In the event of 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.

Medical Scheme Premium Waiver

Sirago will pay the rand amount of the medical scheme premium, not higher than R3 550 per month for a
4-month period. This will be paid to the beneficiary for the upkeep of the medical scheme contributions in event of death or total permanent disability of the Sirago policyholder and where all beneficiaries are linked to a single medical scheme. This benefit is only payable for the medical scheme that the policyholder was on if there is dual medical scheme membership.

Accidental Death

This benefit will pay out for accidental death: at R6 000 for the Sirago policyholder, R5 000 for the adult dependant, and R3 000 for child dependants.

Cancer Cover (Initial Diagnosis)

This benefit will pay out a lump sum of R9 500 per beneficiary in the event where you are diagnosed with malignant cancer from stage 1 for the first time ever. Any cancer prior to inception of the policy or pre-existing cancer is excluded. Skin cancer is specifically excluded from cover on this policy, except malignant melanomas.

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

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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