Gap Cover

Many medical professionals charge over and above the medical aid benefit rate. This means the shortfall or difference will have to be covered by the member, out of pocket, which can become quite costly. Gap provides a financial guardrail against shortfalls and co-payments.

• A 3-month general waiting period applies on all claims except for accidents
• A 12-month waiting period applies on all claims directly or indirectly related to the treatment of scopes (which include minimally invasive scopes, endoscopies, arthroscopies, and hysteroscopies), endometrial ablations, hysterectomy, pregnancy and childbirth, cholecystectomy, wisdom teeth, dental treatment, cataracts, reflux surgery, tonsillectomy, grommets, adenoidectomy, nasal procedures, hernia procedures, joint replacements, and spinal surgery
• A 12-month waiting period applies on any claims relating directly or indirectly to:
  Any pre-existing medical condition you or any of your dependants had at the policy inception, or
  Any advice, diagnosis, care, or treatment you or any of your dependants received or was recommended to receive within the 12-month period prior to the policy inception
• Waiting periods apply to new dependents added to your policy after inception
• If you previously had a gap cover policy with similar benefits, with less than 90 days between the time you ended that policy and activated your policy with us, a 3-month general waiting period and/or the unexpired portion of any previous 12-month waiting period will apply
• Waiting periods for corporate groups may be waived or reduced based on eligibility criteria

• Gap Cover can only cover shortfalls on medical costs. Where a medical scheme excludes treatment, gap cover cannot provide any cover
• Any claim for which your medical scheme has limited the benefit or imposed co-payments because the scheme does not recognise the clinical efficacy or validity of the related procedure or treatment
• Any claim for specialised dentistry or elective maxillofacial surgery, e.g., bridges, implants, frenectomy, orthognathic surgery, etc. (This does not apply to basic in-hospital dentistry, such as wisdom teeth extractions or fillings for young children)
• Any co-payment, deductible, or limitation applied to the medical scheme benefits as a penalty for non-adherence to the medical scheme rules or voluntary use of a non-network provider
• Any claim relating to weight-loss or bariatric surgery
• Any claim submitted more than 4 months after the date of treatment
• Claims not recognised as medically necessary or paid as an ex-gratia / concession
• Experimental, unproven, or unregistered treatments, medicines, or practices
• Any claim that is incurred outside of South Africa (excluding Travel Cover)
• Casualty Cover applies only to care at a casualty facility within 12 hours of an accident and excludes appliances, prosthetics, specialised radiology, and any subsequent treatment after the initial visit to the casualty facility.
• Shortfalls on hospital accounts, day clinics, step-down facilities, or diagnostic services (pathology and radiology), other than co-payments/upfront payments shown on the benefit schedule

Medical Second Opinion (MSO) is an international service offering from our business partner, Mediguide USA, that provides a potentially life-altering service by supporting you in making the most informed decisions possible about your diagnosis and treatment options for serious illnesses.

Diagnostic errors on serious illnesses occur more frequently than is readily acknowledged. This is not unique to SA but an international phenomenon, recognized through several new scientific studies.

MSO ensures that diagnostic mistakes are minimized, offering the best possible health outcome for you and your family when major illness occurs.

Mediguide was established in 1997, and their global network of World Leading Medical Research Centers (WLMRC) ensures that you can access the world’s leading medical minds for a second opinion review when you are faced with a serious medical condition.

This potentially life-altering service is automatically available to all Cinagi members. The qualifying criteria to activate a review are as follows:

Availability of a local and recent diagnosis
You have served your policy’s 3-month waiting period (if applicable)
The condition is not acute, requiring immediate treatment
An in-person evaluation is not required (e.g., mental condition)
Once you have activated an MSO with us, a case manager will be assigned to you to assist in collating all your relevant medical records and then uploading these to the WLMRC you have chosen to have the MSO review done. Your results will then be reviewed and assessed by a multidisciplinary team at the WLMRC, whereafter they will provide you with a comprehensive written report outlining any changes they have made to the initial diagnosis and their recommendation on the best treatment plan.

You will then be free to either discuss this with your local physician or to consult with a new physician – the choice will be up to you.