ULTIMATE GAP COVER
Our most comprehensive options with an
extensive range of benefits
Our most comprehensive options with an extensive range of benefits
Monthly premiums
Why choose Ultimate Gap?
Ultimate Gap Cover offers an extensive range of benefits to ensure you’re fully protected when it matters most. Designed for individuals and families who want complete peace of mind, Ultimate Gap covers a wide variety of medical shortfalls — from specialist fees and hospital co-payments to sub-limits on internal prosthetics, cancer treatments, and emergency room visits. With Ultimate Gap Cover, you get top-tier protection that goes beyond the basics, making it the ideal choice for those who expect nothing less than full coverage.
Key benefits
OAL per beneficiary per annum: R223 000 (from 1 April 2026)
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 an additional 500% above scheme or at the stated benefit value.
For Robotic surgery claims that are reflected on the hospital account, we will cover up to a sub-limit of
R40 000 per policy. We will also cover the shortfall on claims for BMI (Body Mass Index) codes 0018 and 0019 only. Subject to the OAL.
Co-payments and Co-payments charges 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. Subject to the OAL.
Refer to the Cancer Co-payment benefit for claims related to cancer.
Penalty Fee Co-payments
We cover up to R16 000 per claim, with a maximum of 2 claims 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)
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 Shortfall
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 R8 000 per policy, R1 500 per claim.
A R2 000 sub-limit is applicable to private room upgrades. Subject to the OAL.
Sub-limit Enhancer
This benefit has a sub-limit of up to R45 000 per claim, per policy. This benefit caters for all sub-limits. We will provide cover when there is a benefit on your medical scheme option for devices like MRI & CT scans, cochlear implants, intraocular lenses, internal prostheses only, and Transcatheter Aortic Valve Implantation (TAVI) procedure valves. 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.
MRI/CT Scan Benefit
This benefit provides a stated benefit of R5 000 per claim with a maximum of 2 claims per policy, when your Medical scheme benefit is exhausted.
Step-down
There is a sub-limit of R15 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 benefit limits have been reached. Subject to the OAL.
Out-of-hospital Benefits
Primary Care Benefit
This benefit covers you for the shortfall on the consultation fee when your medical scheme pays their scheme agreed rate up to R5 500 per policy, and R850 per claim.
Primary care service providers include:
• GP Consultations
• Dentists Consultations
• Alternative therapist consultations (Chiropractors, Physiotherapists, Biokineticists, occupational therapists, Homeopaths, and Audiologists – if covered by the medical scheme option you are on.) Subject to OAL.
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 R7 000 per policy, and R1 500 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.
Casualty Benefit (REF 1, 2, 3)
There is a sub-limit of R20 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 R2 500 per claim 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 13 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 BENEFITAll costs related to the initial emergency illness event will be covered and paid up to R4 000 per claim 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 12 years and younger who needs emergency treatment outside of normal consultation hours or treatment that can only be done in an emergency facility.
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.
Preventative Care Cover
If your medical scheme option makes provision for preventative care, we will pay up to R8 500 per policy, and up to R1 350 per claim. The following procedures 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.
Alternatively, if there is no benefit available at the time of claim, up to R1 000 will be paid towards the tests/procedures/consultation fee.
- Pap smear
Child Immunisations (Department of Health Formulary) – up to the age of 12 years
Mammogram
- Bone density scans
Appliance Benefit
We will pay up to R9 000 per policy for the shortfall between the medical scheme benefit amount (if there is a rand limit) and the service provider account for the following appliances: hearing aids, wheelchairs, continuous positive airway pressure (CPAP) machines, humidifiers, insulin pumps, glucometers, nebulisers, and Mirena devices.
Trauma Counseling
This benefit covers trauma counselling with a registered medical professional within the first 6 months after a traumatic event, such as but not limited to dread disease, hijacking, and/ or violent crime. We will pay up to
R10 000 per policy.
Accidental Dental Benefit
Should you require a dental procedure as a result of an accident or injury, this benefit covers you for in-room dental procedures up to R20 000 per policy, and to a maximum of R2 500 per fractured tooth.
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. Ongoing treatment must be in line with the registered treatment plan of your medical scheme to access this benefit. Subject to the OAL.
Cancer Benefit - Boost
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.
Cancer Benefit - Breast Reconstruction
After a mastectomy, we will cover up to 500% above the medical scheme rathe for of the claim for reconstructive surgery for the affected breast, if it is approved by your medical scheme. Up to R40 000 will be paid for the reconstruction of the unaffected breast if there is no payment by the scheme. We will also pay up to R4 000 for artificial prosthesis, including but not limited to wigs, breast implants, and post-mastectomy bra prosthesis, should the medical scheme not cover this at all. This benefit is only available within the first 18 months of the initial mastectomy. There is no benefit for any costs related to PMB services, treatments, or medical interventions, unless otherwise stated.
Value-added Benefits
Gap Cover Premium Waiver
Medical Scheme Premium Waiver
Accidental Death
This benefit will pay out for accidental death at R10 000 per dependant registered on the policy. Should the accidental death be a result of a crime, the benefit will increase to R20 000 per dependant.
Cancer Cover (Initial Diagnosis)
This benefit will pay out a lump sum of up to R40 000 when the policyholder or dependant is diagnosed with cancer for the first time, with lump sums based on the stage of diagnosis: R35 000 for stage 2, R37 000 for stage 3 and R40 000 for stage 4.
Sira'Go Baby
Sirago will pay out a lump sum of R2 750 to you, per newborn baby, when the baby is registered on your gap policy within 90 days of birth.
Sirago Medcare - Free Medical Scheme Alternative Dispute Resolution Service (ADR)
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
Explore our gap products
Exact Gap Cover
Get cover for specific procedures excluded by your medical scheme.
From
R227
per month
Exact with Gap & Co-pay Cover
Cover for specific procedures with additional gap and co-payment cover.