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, fully financially dependent on the Principal member and a dependant on the Principal member’s medical aid.
- No age limit for mentally & physically handicapped children who are financially 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.