Gap Cover
A cover option that takes care of the shortfalls
In reality, many medical professionals and facilities charge more than what your medical scheme will pay. This leaves you open to a variety of additional payments that you need to make from your pocket.
Bloom Gap is a way to ensure that these shortfalls are taken care of, leaving you with the peace of mind you need to focus on yourself and your loved ones.
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Although you and your family have medical scheme cover, unexpected medical costs can arise when your medical scheme only refunds you a portion of what your doctors have charged you for treatment.
Bloom Gap Cover is the industry-leading solution giving you comprehensive financial protection against these unforeseen medical costs.
Our Core & Max Gap Cover Options
Primary member
You or your spouse can be the principal member on your Bloom Gap policy.
R241 per month
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Child dependant
Child dependants will be charged child premiums until they turn 24 and a maximum of two children will be charged per family.
R79 per month
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Primary member
You or your spouse can be the principal member on your Bloom Gap policy
R278 per month
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Child dependant
Child dependant will be charged child premiums until they turn 24 and a maximum of two children will be charged per family.
R91 per month
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Cover your shortfall with gap cover
Bloom Gap offers a number of shortfall benefits with our Gap options. Please visit our compare options page or download the Gap brochure to view the complete list.
Gap Cover
In-hospital cover
Comprehensive protection against shortfalls in your medical scheme cover - for medical specialists and surgeons
Specialist cover
If you are admitted to hospital or receive care for approved oncology treatment, your medical scheme may only refund you a portion of what your specialists and surgeons charge for their services. When this happens, we will provide additional cover to pay for these shortfalls
Oncology co-payment cover
We cover 3 different categories of shortfalls oncology. Across all 3 categories, we include cover for modern biological and precision drugs approved by your medical scheme:
- The 20% co-payment applied on all oncology costs
- The 25% or 50% co-payments applied on Precision Cancer Medicines
- Co-payments applied to medicines approved as an ex-gratia benefit by your medical scheme
Upfront payments
If your medical scheme has fixed-value upfront payments on MRI/CT/PET scans, in-hospital endoscopes, in-hospital basic dentistry or defined approved surgical procedures, we will cover these in full. We also provide you with cover for co-payments applied as a percentage of medical costs and where you voluntarily make use of a non-network hospital or day clinic
Limit plus
Should your medical scheme impose a rand limit on internal prosthetic devices (eg, joint replacements, spinal fusions, pacemakers, etc), we will provide additional cover per procedure. Additional cover is also provided for sub-limits on MRI/CT/PET scans, endoscopes, and lens implants
Maternity cover
We cover tariff shortfalls on consultations with a gynaecologist or GP during the 2nd and 3rd trimester
Extended Cover
Casualty cover
For an emergency caused by an accident, we will cover you for x-rays, blood tests, medicines, and fees of attending doctors at a casualty facility
Sports cover
If your treatment at a casualty facility was the result of a sports accident, we will also cover shortfalls on follow-up rehabilitation consultations for physiotherapy or chiropractic treatment
Travel cover
Covers the excess payable on your international travel insurance for medical emergencies while travelling outside the country
Cancer diagnosis
If you are diagnosed with cancer (stage 2+) for the first time after joining, we will pay you a once-off lump sum to assist with any associated non-medical costs. We will also cover the cost of the additional medical scheme contributions if you upgrade your medical scheme option
Extra cover
If you are admitted to the hospital for 3 days or more after an accident, we will pay you a lump sum per day for up to 28 days. If you have a baby that is born 42 days or earlier than your original expected due date, we will pay you a lump sum
Accident cover
For accidental death/permanent disability of an insured, a lump sum is payable - if caused by crime, the benefit doubles
Waiver Protector
Pays your medical scheme and gap cover for 6 months on accidental death/permanent disability of the main member or spouse
Frequently Asked Questions
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.
