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.

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.

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

Gap Cover200 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 3 times the Medical Scheme Tariff less the higher of the Medical Scheme Tariff or the Medical Scheme Option Reimbursement Rate.

We remind you that the Gap Cover200 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.

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

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, CT and PET 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.

The benefit includes a once-off payment per family, per annum for the penalty imposed by a medical scheme for the use of a non-network hospital. The benefit is limited to R10 000.

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.

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

Provides for charges related to Cancer treatment in a private institution subject to the Medical Scheme rules in the form of a co-payment 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.

Extended Cancer Treatment Cover 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, Immunotheraphy, Hormone Therapy, Targeted Therapy (including Small Molecule Drugs), Photodynamic Therapy and/or Stem Cell Transplant.

Treatment includes in-hospital expenses, chemicals, medication and out-patient radiotherapy or chemotherapy however, treatment excludes the cost of Specialist’s consultations. Diagnostic radiology, previously limited to MRI, CT, and PET Scans, now includes Nuclear Scans for mapping of cancer.

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

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

Provides a once off dread disease benefit, limited to the diagnosis of Cancer with the exception of –

• All tumours, which are histologically described as pre-malignant, as non-invasive or as cancer in situ.
• All forms of lymphoma in the presence of any Human Immunodeficiency Virus.
• Kaposi’s sarcoma in the presence of any Human Immunodeficiency Virus.
• Any skin cancer other than malignant melanoma.
• Cancerous cells that have not invaded the surrounding or underlying tissue.
• Early cancer of the prostate gland or breast. (Stage1 described as T1a, N0, M0, G1)
• Persons 65 years or older are excluded.
• Limited to R50,000 per insured person on diagnosis.

This benefit covers the actual Medical Scheme contributions and Gap Cover premium 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.
• Persons 65 years or older are excluded.

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.

This benefit covers the actual Medical Scheme contributions and Gap Cover premium following the death or the total and permanent disability of the Principal Member of the Medical Scheme. Provides benefits for Medical Scheme shortfalls but excludes the Gap Cover 100 benefit. Benefits include – co-payments or deductibles, penalty co-payments,  in-hospital sub-limits, cancer cover and the casualty ward benefit, plus:

• Dread Disease (Severe Illness) Benefit provides a once off dread disease benefit, limited to first diagnosis of Cancer.
  • Limited to R50,000 per insured person on first diagnosis.
  • All tumours, which are histologically described as pre-malignant, as non-invasive or as cancer in situ.
  • All forms of lymphoma in the presence of any Human Immunodeficiency Virus.
  • Kaposi’s sarcoma in the presence of any Human Immunodeficiency Virus.
  • Any skin cancer other than malignant melanoma.
  • Cancerous cells that have not invaded the surrounding or underlying tissue.
  • Early cancer of the prostate gland or breast.(Stage1described as T1a, N0, M0, G1)
  • Seniors excluded.
  • The Dread Disease Benefit terminate at the member reaching the benefit expiry age, or age 65.
• 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.
  • Seniors excluded.

Please note the Ambledown Guardian product may be bought as a stand-alone policy.

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

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.

• LPE Advanced

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

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 Scheme on Medical Scheme benefits. In certain instances these limits can be set per procedure type in an effort to manage exposure.

All Gap Cover Benefits above are limited to R198,660 per insured person per annum.