Gap Core

1. Overall Annual Limit (OAL) for Gap Cover Benefits * R198,660 pppa
2. We cover medical specialists for treatment or surgery provided in hospital, medical oncologists for treatment provided in or out of hospital, and medical specialists for out-patient procedures that would attract a co-payment if performed in hospital Benefit Enhancement up to 500% Subject to OAL
3. We cover gynaecologist or GP consultations during the 2nd and 3rd trimester of pregnancy R425 per consult R1,700 per pregnancy

1. We cover the 20% co-payment applied after reaching the oncology threshold – Subject to OAL

2. We cover the 25% and 50% co-payments applied to approved precision medicines – R13,500 per claim Subject to OAL

3. If your medical scheme approves ex-gratia benefits for oncology medicines, we will provide additional cover for your portion of the costs – R13,500 per claim. Subject to OAL

1. We cover fixed rand value upfront payments for MRI/CT/PET scans, in-hospital endoscopes, in-hospital basic dentistry and defined medical procedures – Subject to OAL

2. We cover other upfront payments (including robotic surgery) – R15,000 per event

3. We cover upfront payments for voluntary use of non-network hospital/day clinic. – R13,000 per event max 1 pa

1. We cover shortfalls when a sub-limit applies to internal prosthetic devices – R46,000 per event

2. We cover shortfalls when a sub-limit applies to MRI/CT/PET scans, endoscopes and intra-ocular lenses – R6,200 per event

1. Cover for emergency treatment at a casualty facility resulting from an accident – R14,000 per event, max 2 pa

2. If the accident was a sports injury, we will also cover shortfalls on rehabilitation consultations – R500 per consult, max 6 pe

1. Cover for the excess on your international travel insurance for medical emergencies – R2,600 per departure

1. For a first lifetime cancer diagnosis made after inception of the policy and waiting periods ‡ – R40,000 Lump Sum

2. If after diagnosis you upgrade your medical scheme benefit option at the first upgrade opportunity, we will provide a waiver for the additional contributions * – R4,400 pm for 12 Months

1. For an admission resulting from an accident and where the admission is 3 days or longer Daily Lump Sum Payable: Tier 1 pays from day 1 to 7 and Tier 2 pays from day 8 to 28.
Tier 1 = R110 per day

Tier 2 = R1,100 per day

2. For a premature Birth that is 42 Days or more earlier than the expected due date – R16,000 per event

1. In the event of accidental death or permanent disability caused by an accident – R28,000 pppa

2. If the event was a direct result of a proven crime, an additional benefit is payable – R28,000 pppa

1. In the event of accidental death or permanent disability of the principal member or spouse, we will cover the cost of the medical scheme contributions and gap cover premiums – R5,800 pm – medical aid 100% on policy