AMBLEDOWN GAP COVER SERIES
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.
2017 Product Range
As a member of a Private Medical Scheme, you would expect that an event in-hospital would be covered in full, this is not so. Most Medical Schemes will cover in-hospital expenses defined as services rendered by a Medical Practitioner at the Medical Scheme rate. However, most specialists today are charging rates that are substantially higher than the Medical scheme rates and you, as the member are liable for the difference, this is known as the tariff gap.
The Ambledown Gap Series is an insurance product that provides cover for you and your immediate family for the shortfall (Gap) resulting from any Medical Practitioner charging above the Medical Aid Tariff for in-hospital surgical procedures and certain out of hospital procedures. The insured will receive a benefit equivalent to the costs incurred as a result of the GAP for any hospital admission as an in-patient. The GAP is defined as services rendered by a medical practitioner who charges above the medical scheme tariff.
AMBLEDOWN GAP COVER SERIES
Product details and benefits
We are pleased to introduce our newest product.
Provides benefits for medical scheme shortfalls but excludes the Gap Cover 100 benefit.
Benefits include: co-payments or deductables, in-hospital sub-limits, cancer cover and the casualty ward benefit.
Please note the Ambledown Guardian product may be bought as a stand-alone policy.
The Ambledown Gap Series is an offering that combines all of the following benefits, ie:
- GAP COVER 100 provides for charges levied by the Medical Services Professionals above the Medical Scheme Tariff for associated services in-hospital and/or the necessity for chemotherapy or radiotherapy for the treatment of cancer on an out-patient basis, and/or the necessity for kidney dialysis on an out-patient basis;
- Limited to 5 times the Medical Scheme Tariff
We remind you that the Gap Cover 100 does not provide for charges above the tariff for the hospital costs or for additional costs of prosthesis, materials and medication. Cover is for the services provided by Specialists, General Practitioners and Medical Professionals such as Physiotherapists during the period of hospitalisation.
- Major Medical Co-payment / Deductible Cover provides for charges in the form of a co-payment or deductible applied for in-hospital admissions and charges in the form of a co-payment or deductible for major medical outpatient treatment limited to specialised diagnostic radiology limited to MRI and CT Scans.
Co-Payment is a procedure specific upfront payment charged by the Medical Aid Scheme payable to the Medical Services Provider prior to undergoing the procedure. The co-payment or deductible amounts applied are as per the rules of the patient’s registered medical scheme.
As per the rules of the co-payment we will not pay a benefit if the co-payment was due to a penalty such as the failure to apply for preauthorisation or where the member did not use a network hospital, then we will not consider such to be a co-payment, but a penalty and we will not pay the benefit. This will include the co-payment or sub-limitation imposed by the medical scheme through agreement with the policyholder where the co-payments or sub-limitations are not indicated in the rules of the medical scheme such as the use of robotic equipment for certain surgical procedures.
- Sub-limitation Cover covers the charges above any sub-limitation imposed by the Medical Scheme for in-hospital admissions.
Sub-limits are limits set by the Medical Aid Scheme on Medical Aid benefits. In certain instances these limits can be set per procedure type in an effort to manage exposure.
- Cancer Cover provides for charges related to cancer treatment in a private institution subject to the medical scheme rules in the form of a copayment or deductible applied after the sub-limitation imposed by the medical scheme for cancer treatment and;
- provides for charges after the sub-limitation imposed by the medical scheme for defined biological cancer drugs for defined oncological conditions and/or specific sub-groups of cancer.
This benefit provides for cancer treatment in a private facility where a cost incurred exceeds the R200,000 threshold in respect of biological and/or traditional cancer treatment. Treatment includes in-hospital expenses, chemicals, medication and outpatient radiotherapy or chemotherapy however treatment excludes the cost of specialist’s consultations.
- Casualty Ward Benefit covers you for treatment received in a casualty unit of a hospital provided that such treatment is not for routine physical treatment or any other medical examination or treatment other than emergency medical treatment.
You are covered when immediate treatment is required and your medical scheme does not provide you with cover and you become liable to pay the cost of the casualty event. This benefit will cover the facility fee, consultations, medications, radiology and pathology associated with admission to a registered hospital’s casualty facility.
- Treatment in a casualty unit of a hospital shall be limited to R10 000 per family per annum.
“Emergency” means the sudden and at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or death. The determination of an Emergency will be done through diagnosis (through classification by the attending Medical Practitioner and / or the Casualty Unit) and not on symptoms presented. The Medical Practitioner that treated you and / or the Casualty Unit that you have been treated in should use the correct codes and classification on the invoices they send to you and /or your medical aid.
All Gap Cover Benefits above are limited to R150,000 per insured person per annum
Dread Disease (Severe Illness)
Provides a once off dread disease benefit, limited to diagnosis of cancer.
- Limited to R50,000 per insured person on diagnosis.
The lump sum benefit will apply on first diagnosis of cancer. The benefit will be excluded for any current member who has been diagnosed prior to inception or during the period of cover and is payable once in a lifetime per insured person.
Premium Waiver Benefit
This benefit covers the actual medical scheme contributions following the death or the total and permanent disability of the Principal Member of the Medical Scheme.
- Limited to a benefit equal to the total value of Medical Aid Scheme Contribution calculated for 6 months.
In the event of the death of the principal member of the Medical Aid Scheme or in the event that an accident or illness resulted in the total permanent disability of the principal member, the company shall pay the Registered Medical Aid Scheme the Medical Aid Scheme Contribution for 6 months commencing on the 1st day of the following month from the date the incident occurred.
GAP LPE Advanced
The Listed Procedure Enhancer Is a benefit that combines GAP COVER 100 and a selection of listed procedures which provides a benefit equal to the cost of in-hospitalisation and associated medical expenses relating to one of the procedures less the cover provided by the Medical Scheme option, ie:
GAP COVER 100 provides for charges levied by the Medical Services Professionals above the Medical Scheme Tariff for associated services in-hospital and/or the necessity for chemotherapy or radiotherapy for the treatment of cancer on an outpatient basis, and/or the necessity for kidney dialysis on an out-patient basis;
- Limited to 5 times the Medical Scheme Tariff
- The Company shall not be liable for any charges incurred under GAP COVER 100 due to the following:
We remind you that Gap Cover 100 does not provide for charges above the tariff for the hospital costs or for additional costs of prosthesis, materials and medication. Cover is for the services provided by Specialists, General Practitioners and Medical Professionals such as Physiotherapists during the period of hospitalisation.
The Listed Procedures mentioned below are limited to the actual costs incurred, calculated at the Medical Scheme Rate and subject to a specific limitation of R75,000 in aggregate per insured person per annum.
- In-hospital management of Dentistry, limited to impacted teeth for minors under 18 years or reconstructive plastic surgery due to an accident that occurs during the period of cover.
- Functional nasal surgery.
- Surgery for oesophageal reflux and hiatus hernia.
- Back and neck treatment or surgery.
- Joint replacements, including but not limited to hips, knees, shoulders and elbows.
- Cochlear implants, auditory brain implants and internal nerve stimulators – this includes procedures, devices and processors.
- Removal of varicose veins.
- Skin disorders including benign growths and lipomas.
The Listed Procedures and Gap Cover benefits above are subject to an overall benefit limitation of R150,000 in the aggregate per Insured Person per annum.
Underwriting matters which are of importance
- Please note that this product will assist with the shortfalls for in-hospital expenses and does not provide cover for day-to-day expenses once your Medical Savings Account has been depleted, nor will it cover your expense if you are in the self-payment gap.
- The minimum entry age for the Principal insured person is 18 and the maximum entry age is 65. Applicants 66 and older have the option of selecting products for seniors.
- Extended Family Dependants: A family is defined as the principal insured and immediate family which includes the spouse and children. Extended family dependants are not considered as part of the family.
- Eligible child is a person who has not attained the age of 21 and this age may be extended to 26 in respect of a child who is unmarried, fully financially dependent on the Principal Insured and a dependant on the Principal Insured Persons’ medical aid scheme.
- Adopted and fostered children are eligible dependants if they are under 21 years of age, or they are under 26 years of age and who is unmarried, fully financially dependent on the Principal Insured and a dependant on the Principal Insured Persons’ medical aid scheme.
- There is no age limit for mentally or physically handicapped children who are financially dependent on the principal insured and a dependant on the Principal Insured Persons’ medical aid scheme. There is no limit to the amount of children covered by the policy.
- Continuation: Any individual may apply to continue cover if that individual was a member of group policy and terminates his employment. Ambledown has the right to alter the premium rates to individual rates or adjust the premium for the additional costs of the debit order and other administrative tasks.
- Benefit upgrades: A 3 month general waiting period and 12 month pre-existing clause will apply to the additional benefits obtained when a member upgrades cover. The existing benefits enjoyed prior to the upgrade will not be subjected to the waiting periods mentioned.
- A 12 month pre-existing clause applies. The clause excludes claims for any treatment received for a condition for which treatment or advice has been received in the 12 months prior to the inception of the policy. The intention is to exclude any benefit where treatment or advice was received 12 months prior to inception. Once membership is greater than 12 months, then benefits are payable regardless of the date in which the illness manifested itself or the injury occurred.
- No benefits will be payable during a general 3 month waiting period for all treatment received unless the treatment was required as a result of an accident (external violent physical means).
- No benefit shall be payable for the severe illness benefit if the Insured Person was diagnosed with Cancer (as defined) prior to the inception of this Policy.
Download Gap Cover pdf brochures here: