The Listed Procedure Enhancer Is a benefit that combines Gap Cover 100, Casualty Ward Benefit 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 Cover100 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 6 times the Medical Scheme Tariff less the higher of the Medical Scheme Tariff or the Medical Scheme Option Reimbursement Rate.
- The Company shall not be liable for any charges incurred under Gap Cover 100 due to the following:
- Co-Payment.
- Sub-Limitation.
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 R100,000 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.
- Bunionectomy.
- Arthroscopy.
- Removal of varicose veins.
- Skin disorders including benign growths and lipomas.
- Tonsillectomies.
- Myringotomies.
- Adenoidectomies.
- 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 is subject to a specific limitation of R11,000 per insured person 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 R198,660 per insured person per annum.*
*The Policy Benefits are subject to an overall benefit limitation of R198,660 or any higher amount published by the Regulator in aggregate per Insured Person per annum