What is Gap Cover?
Gap cover is a short term insurance product that provides cover for:
- The Principal member and immediate dependants that are registered as dependants on the Principal member’s South African Registered Medical Scheme.
- Service providers such as specialists, surgeons, anaesthetists etc. who charge in excess of the medical scheme tariff for authorised in-hospital procedures and specified authorised out of hospital procedures.
- Limited to five (5) times the Medical Scheme tariff
- Out-patient chemotherapy, radiotherapy and kidney dialysis
Gap Cover does NOT provide cover for:
- Charges above the Medical Scheme tariff for hospital costs and medication, e.g. cost of bed, food, bandages etc.
- Any procedure not covered or declined by the Medical Scheme.
- Any PMB (Prescribed Minimum Benefits - charges which should be provided for by the Medical Scheme, this includes ward fees and theatre stock charges)
- Split billing.
- Short falls or penalties related to the use of an non-DSP or out of network provider.
- Day to day expenses once the medical savings account has been depleted.
- No benefit provided on the medical aid option.
- Extended family members who are dependants.
Please refer to the master policy document for the full list of exclusions.
Who is covered?
- Principal member and immediate family (spouse and children) who are listed as dependants on the principal member’s medical aid.
- Principal member requirements:
- Minimum age of entry is 18
- Maximum age of entry is 65 with no cessation age
- Minimum age of entry for the gap senior range is 66 with no cessation age
- One Spouse (if more than one, an irrevocable nomination of one of the eligible spouses is required).
- Eligible children;
- Natural, adopted, step child and fostered
- Unmarried and not yet attained the age of 21
- This age can be extended for an eligible child who has not yet attained the age of 26 on condition that the child is unmarried and a dependant on the Principal member’s medical aid.
- No age limit for mentally & physically handicapped children who are wholly dependent on the Principal member and a dependant on the Principal member’s medical aid.
- There is no limit to the amount of children that can be covered.
Who is not covered?
- Children that are:
- age 21 or older
- age 27 or older even if the child is unmarried, fully financially dependent on the Principal and a dependant on the Principal member’s medical aid
NOTE: Any parent, relative or child that is not covered under the Principal member’s gap cover can take out their own gap cover provided they belong to a South African registered Medical Scheme.