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Final demarcation regulations
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Ambledown Final Demarcation RegulationsGENERAL NOTICE
FINAL DEMARCATION REGULATIONS:

We refer to our general notice provided on the 6 December 2016 which dealt with the Final Demarcation Regulations that have taken effect since 1 April 2017.

MEDICAL SCHEME SHORTFALL COVER:

There is still much confusion regarding the commission table, whether the table is intended to be tiered, or a commission is paid depending on the overall policy premium.

To clarify a number of matters, including commission, Ambledown has requested a meeting with National Treasury, the CMS and the FSB. National Treasury has kindly offered to facilitate the meeting with the other regulatory bodies.

Important: New employees of employer groups (that have signed and accepted a quote) have entered into a contract with the insurer.  We will therefore continue to provide the product offered, including the current limitation until 1 January 2018.

Ambledown will be adjusting products for new members from 1 April 2017:

  1. Gap Cover and Gap Plus will remain the same. A R150,000 overall limit per insured person per annum (not family) will apply;
  2. Gap Plus & Extend, Gap Shield are no longer available to new members; from 21 April 2017 Gap Elite will no longer be offered to new members.
  3. Gap Select and Gap Supreme will be improved to allow for a better Cancer Benefit. We will allow for R50,000 once off cancer benefit on diagnosis. The intention to offer a lump sum on diagnosis must therefore exclude any member that has been an Ambledown client and was diagnosed prior to inception or during the period of cover. These members will need the maximum benefit allowed for cancer treatment. It is our opinion that they retain the cancer benefits.
  4. Important: The Gap Select and Gap Supreme products will remain the same for seniors, for the sake of keeping premium respectable we must exclude seniors from the dread disease benefit. This benefit will also cease at age 65. 
  5. We have also created a new product (Ambledown Guardian) that includes all medical scheme shortfalls but excludes Gap cover. The product will provide benefits for:
    • Co-payments (including MRI and CT Scans on an outpatient basis),
    • Cover for the cost of sub-limitation imposed by the medical scheme,
    • Our traditional cancer and biological cancer cover for co-payments or sub-limitations limited by medical schemes in private practice, and
    • The casualty emergency cover.
       

 

GAP SELECT

Benefit

Category

Subject to overall Limitation

Categorised as a Health & Accident Policy

Gap cover (limited to 5 times the tariff)

Medical Scheme Shortfall

Yes

Yes

Co-payments / Deductibles for in-patient treatment, including certain outpatient procedures listed in the currently policies.

NO SUB-LIMITATION APPLIES

Medical Scheme Shortfall

Yes

Yes

Co-payments / Deductibles for outpatient specialised radiology. (MRI and CT Scans)

NO SUB-LIMITATION APPLIES

Medical Scheme Shortfall

Yes

Yes

Sub-limitations (Costs incurred for any sub-limitation imposed by the medical scheme)

NO SUB-LIMITATION APPLIES

Medical Scheme Shortfall

Yes

Yes

Cancer Benefit (including sub-limitations and/or co-payments) and including traditional cancer treatment and biological drug treatment.

Medical Scheme Shortfall

Yes

Yes

Casualty Ward fees
(Costs incurred for any emergency not met by the medical scheme)

A R10,000 sub-limitation applies

Medical Scheme Shortfall

Yes

Yes

R50,000 once off dread disease on Diagnosis:

Limited to Cancer

Dread Disease

No

No

 

GAP SUPREME

Benefit

Category

Subject to overall Limitation

Categorised as a Health & Accident Policy

Gap cover (limited to 5 times the tariff)

Medical Scheme Shortfall

Yes

Yes

Co-payments / Deductibles for in-patient treatment, including certain outpatient procedures listed in the currently policies.

NO SUB-LIMITATION APPLIES

Medical Scheme Shortfall

Yes

Yes

Co-payments / Deductibles for outpatient specialised radiology. (MRI and CT Scans)

NO SUB-LIMITATION APPLIES

Medical Scheme Shortfall

Yes

Yes

Sub-limitations (Costs incurred for any sub-limitation imposed by the medical scheme)

NO SUB-LIMITATION APPLIES

Medical Scheme Shortfall

Yes

Yes

Cancer Benefit (including sub-limitations and/or co-payments) and including traditional cancer treatment and biological drug treatment.

Medical Scheme Shortfall

Yes

Yes

Casualty Ward fees

(Costs incurred for any emergency not met by the medical scheme)

A R10,000 sub-limitation applies

Medical Scheme Shortfall

Yes

Yes

R50,000 once off dread disease on Diagnosis:

Limited to Cancer

Dread Disease

No

No

Premium waiver for Medical Scheme Contributions for a period of 6 months on the death or permanent disability of the Principal Insured

Premium Waiver

No

No

 

New Product
AMBLEDOWN GUARDIAN

Benefit

Category

Subject to overall Limitation

Product categorised as a Health & Accident Policy

Co-payments / Deductibles for in-patient treatment, including certain outpatient procedures listed in the currently policies.

Medical Scheme Shortfall

Yes

Yes

Co-payments / Deductibles for outpatient specialised radiology. (MRI and CT Scans)

NO SUB-LIMITATION APPLIES

Medical Scheme Shortfall

Yes

Yes

Sub-limitations (Costs incurred for any sub-limitation imposed by the medical scheme)

NO SUB-LIMITATION APPLIES

Medical Scheme Shortfall

Yes

Yes

Cancer Benefit (including sub-limitations and/or co-payments) and including traditional cancer treatment and biological drug treatment.

Medical Scheme Shortfall

Yes

Yes

Casualty Ward fees

(Costs incurred for any emergency not met by the medical scheme)

A R10,000 sub-limitation applies

Medical Scheme Shortfall

Yes

Yes

The commissions (for persons other than seniors) for all products will be 20%, regardless of the ruling by the Regulators on what was intended by the peculiar drafting of the commission tables. The following is a breakdown by policy and product category:

Product

Individuals (Old)

Individuals
New

Insurance Category breakdown

Medical Scheme Shortfall

Dread Disease

Premium Waiver

2017  Gap

 R 230.00

 R230.00

230.00

-

-

2017  Gap Plus

 R 290.00

 R290.00

290.00

-

-

2017  Gap Select

 R 350.00

 R350.00

295.00

55.00

-

2017  Gap Supreme

 R 375.00

 R375.00

295.00

55.00

25.00

2017 LPE Advanced

 R 235.00

 R235.00

235.00

-

-

Ambledown Guardian

New

 R130.00

130.00

-

-

 

SENIORS

  1. The products above will be made available to all new members aged 66 (age attained) and younger.
  2. Gap Elite and Gap Supreme will be made available without the dread disease. The dread disease will cease at age 66 (age attained).
  3. Premium for senior products are as per the following table:

 Product

Standard Rates

Senior Rates

Gap

 R 230.00

 R 365.00

Gap Plus

 R 290.00

 R 385.00

Gap Plus & Extend

 R 340.00

 R 400.00

Gap Select

 R 350.00

 R 525.00

Gap Supreme

 R 375.00

 R 560.00

LPE Advance

 R 235.00

 R 350.00

Ambledown Guardian

 R 130.00

 R 185.00

 

 

 

Ambledown is an authoroised Financial Services Provider

This is not a medical scheme and the cover is not the same as that of a medical scheme
This policy is not a substitute for medical scheme membership.

The details provided are only for marketing purposes. The Master Policy issued is the source of all benefits, rights, and obligations and exclusions. To determine your individual needs, we suggest that you contact your broker and request advice from him /her.

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Ambledown is an authorised Financial Services Provider

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