Welcome to Ambledown

Ambledown is a health and accident underwriting agency providing underwriting management and claims administration.

We are one of the leading health insurance product providers in South Africa with over 150,000 Gap Cover (or similar) policy holders. We are founded on the principles of innovation and in providing the right product to the consumer. Our products are designed to protect the individual consumer who is a member of a Medical Scheme but is still at risk (often for tens of thousands of Rands) for unforeseen additional charges during a period of hospitalisation.

As an underwriting agency we do not assume any insurance risk ourselves and the revenues generated are based entirely on management fees and profit commissions.

We believe that the individual consumer should select the medical aid benefit option that is most appropriate and purchase the Ambledown cover for such unforeseen events. We aim to provide products that are affordable and applicable to all medical scheme benefit options.

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Ambledown is a leading health insurance product provider in South Africa. Our Ethics: It is our fundamental nature to avoid products that reside in the “grey” areas of the law, we do not look to exploit legal technicalities or find creative “loopholes” in legislation.

About Gap Cover

Learn more about what gap cover is and what is included in our gap cover products. We have a variety of gap cover options to suit your needs.

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 less the higher of the Medical Scheme Tariff or the Medical Scheme Option Reimbursement Rate
  • Out-patient chemotherapy, radiotherapy and kidney dialysis
  • Hospital co-payments
  • Sub limit cover
  • Casualty ward benefit
  • Cancer cover

2019 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 Cover 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.

Gap CoverGap PlusGap SelectGap EliteGap SupremeGap LPE AdvancedAmbledown Guardian

Gap cover does not cover the following:

  • 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 in our gap cover products? 

  • 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 will not be covered in your gap cover policy? 

  • Parents
  • Relatives
  • Children that are:
  • age 21 or older
  • age 26 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.

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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 less the higher of the Medical Scheme Tariff or the Medical Scheme Option Reimbursement Rate
  • Out-patient chemotherapy, radiotherapy and kidney dialysis
  • Hospital co-payments
  • Sub limit cover
  • Casualty ward benefit
  • Cancer cover
Gap cover products

2019 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 Cover 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.

Gap CoverGap PlusGap SelectGap EliteGap SupremeGap LPE AdvancedAmbledown Guardian
Gap cover does not provide cover for:

Gap cover does not cover the following:

  • 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?

Who is covered in our gap cover products? 

  • 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?

Who will not be covered in your gap cover policy? 

  • Parents
  • Relatives
  • Children that are:
  • age 21 or older
  • age 26 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.

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Our Ethics

Ambledown will not as a rule, create health insurance products as a substitute for a medical scheme.  We recognise that they undermine the general health risk pool and try to dissociate ourselves from this practice. Where we deal with consumers from various socio-economic groups that cannot afford membership of a medical scheme (given the onerous cost implications of prescribed minimum benefits), then we believe it appropriate to offer insurance products that provide at least a basic level of cover to the member. We recognise that an otherwise innocuous range of insurance products can be packaged and marketed in such a way that they compete with medical schemes. By selectively targeting low risk lives, one can undermine the medical scheme risk pool. In this instance it is not the products per se, but the application of the product that is offensive.

Testimonials

Our happy clients are enjoying quality gap cover benefits and excellent service

*the following identities are protected by use of pseudonyms*

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