Sirago Underwriting Managers

Ultimate Gap Cover

Our most comprehensive option with an extensive range of benefits.

Key Benefits

OAL per beneficiary per annum:
R183 000

in-hospital gap benefits
In-Hospital Benefits

Gap Cover
Co-payments
Co-payments Charged as a Percentage
Penalty Fee Cover
Day Hospital/Clinic and/or In Room Surgical Procedures Cover
PMB Cover
Hospital Account Shortfalls
Sub-limit Enhancer
Step-down

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cancer benefits
Cancer Benefits

Cancer Co-payment Benefit
Cancer Benefit - Boost
Cancer Benefit - Breast Reconstruction

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

Primary Care Consultation Benefits
Emergency Room Cover
Day-to-day Specialist Consultation Fee
Preventative Care Cover
Appliance Benefit
Trauma Counselling

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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

We settle claims at an additional 500% above Medical Scheme rates or at the stated benefit value.
In the event of a claim for robotic surgery that appears on the hospital account, we will cover up to a sub-limit of R33 000 per policy, limited to R16 500 per claim with a maximum of 2 claims per policy.
The shortfall on BMI codes 0018 and 0019 are paid up to a sub-limit of R15 000 per policy.

Co-payments

Co-payments are the excesses imposed by your medical scheme
and can be paid to a maximum rand limit for specified procedures
or tests. This includes co-payments imposed by medical schemes
for hospital admissions, scans, and surgical procedures. Subject to
the OAL.

Co-payments Charged as a Percentage

If your medical scheme defines a co-payment for procedures as a
percentage of the claim, the amount covered will be limited to R17 500 per claim for all associated costs related to the event.

Penalty Fee Cover

This benefit has a sub-limit of R13 000 per claim and 3 claims per policy. 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.

 

Refer to the cancer co-payment benefit for claims related to cancer.
Co-payments for administration charges are specifically excluded from cover on this
policy.

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

If you choose to have, or your medical scheme pre-authorises treatment that would normally be performed in a hospital, at a day hospital, clinic, or in a doctor’s room, we will pay the gap portion of claims.

PMB Cover

PMB Cover on this policy is 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. Subject to the OAL.

Hospital Account Shortfalls

This benefit will cover any charges on the hospital account that the medical scheme has not paid for, this includes for example items like consumables and take-home medication.
We pay up to R6 000 per policy, R1 300 per claim, and 3 claims per beneficiary.
A R2 000 sub-limit is applicable to private room upgrades.

Sub-limit Enhancer

This benefit has a sub-limit of R100 000 per policy and R25 000 per claim. Limited to 4 claims per policy.
The sub-limit enhancer benefit applies when you have exceeded your medical scheme benefit limit for MRI & CT scans, intraocular lenses, and internal prostheses only.

Step-down

There is a sub-limit of R11 000 per policy if your medical scheme provides benefits for rehabilitation as an in-patient in a step-down
or sub-acute facility.

Cover will be provided for ongoing treatments, resulting from an accident, stroke, or cancer treatment, when your medical scheme benefits have been exhausted.

Out-of-hospital Benefits

This benefit covers the difference between the medical scheme rate and the rate that the service provider charges for the consultation.
A sub-limit of R5 000 applies, and R400 per claim.
Primary care service providers include:
• GPs
• Dentists
• Alternative therapists (chiropractors, physiotherapists
biokineticists, occupational therapists, homeopaths, and
audiologists, only).

Emergency Room Cover

There is a sub-limit of R12 000. This benefit covers an emergency at any registered emergency, 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
emergency facility if no emergency hospital is available within a 30 km radius.


ACCIDENT / TRAUMA BENEFIT
All costs related to the accidental event will be covered.


ILLNESS BENEFIT
All costs related to the emergency illness event will be covered and paid up to R2 000 of the sub-limit. 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 room.


CHILD EMERGENCY ILLNESS BENEFIT
This benefit is applicable to children 8 years and younger who require out of normal consultation hours or treatment that can only be done in an emergency room. 

Day-to-day Specialist Consultation Fee

This benefit covers the difference between the medical scheme rate and the rate charged by the specialist for consultation only, up to the available sub-limit of R6 500 per policy, R1 350 per claim, and 4 claims per beneficiary. This depends on the benefit design of your chosen medical scheme option.

Preventative Care Cover

A sub-limit of R8 000 applies. Claims will be paid up to R1 000 per claim, limited to 4 claims per beneficiary. The following tests or treatments are covered: Pap smear, cholesterol test, blood glucose test, flu vaccination,
childhood immunisation (Department of Health formulary) – up to the age of 12 years, bone-density scans, prostate-specific antigen tests, mammogram, and contraceptive implantation only.

Appliance Benefit

We will pay up to R7 000 per policy for the difference between what the medical scheme benefit amount and what the service provider charges for the following appliances: hearing aids,
wheelchairs, continuous positive airway pressure (CPAP) machines, humidifiers, insulin pumps, glucometers, nebulisers,
and Mirena device.

Trauma Counselling

This benefit covers trauma counselling with a registered medical professional after a traumatic event.
A sub-limit of R8 000 per policy applies, R950 per claim for children 13 years and younger, R750 per claim for any dependant 14 years and older, and 3 claims per dependant.
You will be covered within the first 6 months after the incident.

Cancer Benefits

Cancer Co-payment Benefit

This benefit applies if your medical scheme cancer benefit has been reached and a percentage co-payment is imposed. This benefit incorporates co-payments for ongoing cancer-related treatments and biological drugs. You need to be on a registered treatment plan with your medical scheme to access this benefit.

Cancer Benefit – Boost

This benefit applies if your medical scheme option for cancer has a defined rand limit. 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 OAL.

 

 

 

 

Cancer Benefit – Breast Reconstruction

After a mastectomy, we will cover up to 300% of the claim for reconstructive surgery for the affected breast, if it is approved by your medical scheme.
Up to R25 000 will be paid for the reconstruction of the unaffected breast, if there is no payment by the scheme.
This benefit is available within the first 18 months of the initial mastectomy.

Value Added Benefits

Gap Cover Premium Waiver

When you die or become totally and permanently disabled, we will keep the premiums for your policy as a credit for 12 months. This may be claimed by the surviving adult dependant.

Medical Scheme Premium Waiver

When the policyholder dies or if you become totally and
permanently disabled and all your beneficiaries are linked to the same medical scheme, we will pay a claim for the medical scheme premium of the actual rand amount of the contribution, up to the sub-limit of R5 000 per month for 6 months. If your dependants are on different medical schemes, this benefit is only payable for the medical scheme of the policyholder.

Accidental Death

This benefit will pay out for accidental death: at R15 000 for you (the policyholder), R10 000 for the adult dependant, and R5 000 for child dependants.

Cancer Cover (Initial Diagnosis)

This benefit will pay out a lump sum of R25 000 on the initial diagnosis of malignant cancer per beneficiary. This excludes any incidence of cancer or pre-cancer before the inception of this policy and specifically excludes skin cancer.

Sira’Go Baby

This benefit has a R2 500 sub-limit for each new-born baby, and covers the following:
For the mother, after confirmation of pregnancy:
Midwife, consultations, pathology, ultrasounds, 3-D, and 4-D scans during pregnancy.
For the newborn: Audiologist and paediatric
ophthalmologist consultations and any additional childhood immunisations.
• Upgrade to a private room during the confinement.

To add a new-born baby to the policy, we must receive the birth certificate within 90 days of the child’s birth.

If a PMB claim does not qualify as a valid claim, you will have access to MedCare’s free alternative dispute resolution (ADR)
service for all claims exceeding R12 000.
You can also access the MedCare service for all claims less than R12 000, including all potential medical scheme disputes, at a 50%, 15%, or 10% discounted rate depending on the required service.
Your financial advisor can also access this service on your behalf and will have access to the MedCare website.

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