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 copayments 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, eg 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, obesity including related modifier codes, infertility and sleep studies • Any claim submitted more than 4 months after 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 (excl Travel Cover)
• Any claim that arises from a medical service provider and/or medical scheme not complying with prevailing legislation
• Casualty Accident Cover applies only to emergency treatment at a casualty facility within 12 hours of an accident, and excludes appliances, prosthetics and any subsequent treatment after the initial emergency 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
• Casualty Illness Child Cover applies only to emergency treatment for a child younger than 12 at a casualty facility after hours (Mon-Fri between 6pm and 6am plus any hours of a weekend or public holiday) – excludes appliances, prosthetics and any subsequent treatment after the initial visit to the casualty facility