Plus Gap Cover

Your whole policy has an Overall Annual Limit (OAL) of R164 000 per beneficiary to utilise.

INDIVIDUAL, UNDER 54
R324 / mon
INDIVIDUAL, 65+
R475/ mon
FAMILY, UNDER 54
R370 / mon
FAMILY, 65+
R543/ mon

Benefits

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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

Are 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. Copayments related to cancer are catered for in a separate benefit category.

Co-payments Charged as a Percentage

If your medical scheme defines your co-payment as a percentage of the benefit, your co-payment benefit will be limited to a maximum payment of R13 000 per claim.

Penalty Fee Cover

Subject to a sub-limit of R6 500 per claim, a maximum of 2 claims per policy per annum for the voluntary use of a non-designated service provider/network hospital. This includes the use of a partial cover network hospital as determined by your medical scheme.

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

Will settle the Gap portion of claims.

PMB Cover

This benefit will cover the shortfall resulting from the voluntary use of a nondesignated service provider for planned procedures, except in the event of an emergency.

Hospital Account Shortfalls

R3 000 sub-limit per policy per annum. R800 per claim, 3 claims per beneficiary per annum.

Sub-limit Enhancer

Subject to a sub-limit of R36 000 per policy per annum. Subject to R12 000 per claim. Maximum of 2 claims per beneficiary limited to 3 claims per policy per annum. The sub-limit enhancer benefits are limited to MRI scans and CT scans only.

Out-of-hospital Benefits

Emergency Room Cover

A sub-limit of R7 000 is applicable. This benefit covers an emergency at any registered emergency facility when you require immediate medical treatment due to an accident or illness. The following benefits collectively accumulate to the sub-limit. Accident benefit: all costs related to the accidental event will be covered and paid to a maximum value of the sub-limit available, whether you are liable to pay the costs related to the emergency event out of your own pocket or if your medical scheme pays from your savings account. Illness benefit: when you visit an emergency room in a medical emergency as a result of illness, we will cover the Gap portion only if the medical scheme has paid a portion.

Day-to-day Specialist Consultation Fee

R4 500 sub-limit per policy. Maximum of R825 per claim. 3 claims per beneficiary per annum for the Gap portion only.

Preventative Care Cover

R4 000 sub-limit per policy. R1 000 per claim, maximum of 3 claims per beneficiary per annum. Defined as pap smears, cholesterol tests, blood glucose tests, flu vaccinations, childhood immunisations, bone density scans, prostate-specific antigen tests, mammograms and contraceptive implantation.

Cancer Benefits

Cancer Co-payment Benefit

The Cancer Co-payment Benefit is applied once your medical scheme cancer benefit has been reached and a percentage co-payment is imposed. This benefit incorporates co-payments, and co-payments related to biological drugs. In order to access this benefit, you need to be on a registered treatment plan with your medical scheme.

Cancer Benefit - Boost

The Cancer Boost benefit is limited to R50 000 per beneficiary per annum. This benefit is restricted to policyholders where their medical scheme option has a defined rand limit for cancer treatment. The Cancer Boost benefit can only be claimed once your rand limit on your medical scheme cancer benefit has been reached and you require ongoing treatment. This benefit is dependent upon the insured having already been registered on the medical scheme’s cancer programme. The Cancer Boost benefits are limited to those that were determined within the approved medical scheme treatment plan which must be submitted to Sirago upon application for this benefit.

Cancer Benefit - Breast Reconstruction

In the event of the medical scheme approving reconstructive surgery on the affected breast, we will cover the Gap portion up to 200% of the claim. In addition to this, Sirago will make available up to R16 000 for the reconstruction of the non-affected breast. This benefit is available within the first 12 (twelve) months of the initial mastectomy. We require, subject to Sirago protocols, which include, but are not limited to: medical scheme pre-authorisation and a motivation/letter from your treating provider.

Cancer Benefit - PMB

Please note the above benefits are only available in the event that the treatments do not form part of the legislative PMB framework.

The policy wording supercedes any marketing documentation and all benefits will be payable against the policy wording terms and conditions only.

Value Added Benefits

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Gap Cover Premium Waiver

In event of death or total permanent disability of the policyholder of the Sirago policy. The Premium Waiver is directly linked to your policy premium per month as indicated in your schedule of insurance. This benefit is not paid in cash but held as a credit against the policy for the applicable 12 month period. Should there be any premium adjustments within the 12 month period, the credit balance available for the rest of the waiver period will be adjusted accordingly. This benefit cannot be transferred, ceded or converted to cash.

Medical Scheme Premium Waiver

Payable in event of death or total permanent disability of the principal policyholder of the Sirago Gap Cover. In the event of dual medical scheme membership, this benefit is only payable in event of death or total permanent disability of the principal policyholder. Sirago will pay the medical scheme premium to the actual amount of the contribution, but not higher than the sub-limit of R3 250 per month for a 6 month period which will be paid to the beneficiary for the upkeep of their medical scheme contributions. In order to receive the benefit, the Gap Cover policy and medical scheme membership must remain active during this period. A certificate of membership from your medical scheme must be presented monthly for authentication of current membership.

Accidental Death

R8 000 principal, R5 000 adult dependent, R3 000 per child per policy per life.

Cancer Cover (Initial Diagnosis)

This benefit will pay you a lump sum of R14 000 upon the initial diagnosis of malignant cancer per beneficiary per annum as defined. This excludes any incidence of cancer/pre-cancer prior to the inception of the policy.

Sira-Go’ Baby

A branded Sirago welcome gift will be posted to your physical address, or delivered to your contracted broker, as per your application form upon receipt of the instruction to add the new-born child. The instruction to add the child to the policy must be submitted within 31 days of the birth of the child. (Subject to availability. Please allow 6 weeks for delivery.)

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Sirago Underwriting Managers (Pty) Ltd is an Authorised Financial Services Provider (FSP:4710).
Underwriting Agency for GENRIC Insurance Company Limited (FSP:43638).
GENRIC is an Authorised Financial Services Provider and Registered Short-term Insurer.

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Contact

Tel: 010 599 1163

Fax: 086 508 2292

Email: info@sirago.co.za

Address: Midrand Business Park, Building 3, 563 Old Pretoria Main Road, Midrand, 1685

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