About Gap Cover

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About Gap Cover

About Gap Cover

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

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. .

View our gap cover products

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.

Underwriting

Please note that this product will assist with the shortfalls for in-hospital expenses and does not provide cover for day-to-day expenses once your Medical Savings Account has been depleted, nor will it cover your expense if you are in the self-payment gap.
The minimum entry age for the Principal insured person is 18 and the maximum entry age is 65. Applicants 66 and older have the option of selecting products for seniors.
Extended Family Dependants: A family is defined as the principal insured and immediate family which includes the spouse and children. Extended family dependants are not considered as part of the family.
Eligible child is a person who has not attained the age of 21 and this age may be extended to 25 (under 26) in respect of a child who is unmarried and a dependant on the Principal Insured Persons’ Medical Aid Scheme.
Adopted and fostered children are eligible dependants if they are under 21 years of age, or they are under 26 years of age and who is unmarried and a dependant on the Principal Insured Persons’ Medical Aid Scheme.
There is no age limit for mentally or physically handicapped children who are wholly dependent on the principal insured and a dependant on the Principal Insured Persons’ Medical Aid Scheme. There is no limit to the amount of children covered by the policy.
Continuation: Any individual may apply to continue cover if that individual was a member of group policy and terminates his employment. Ambledown has the right to alter the premium rates to individual rates or adjust the premium for the additional costs of the debit order and other administrative tasks.
Benefit upgrades: A 3 month general waiting period and 12 month pre-existing clause will apply to the additional benefits obtained when a member upgrades cover. The existing benefits enjoyed prior to the upgrade will not be subjected to the waiting periods mentioned.
A 12 month pre-existing clause applies. The clause excludes claims for any treatment received for a condition for which treatment or advice has been received in the 12 months prior to the inception of the policy. The intention is to exclude any benefit where treatment or advice was received 12 months prior to inception. Once membership is greater than 12 months, then benefits are payable regardless of the date in which the illness manifested itself or the injury occurred.
No benefits will be payable during a general 3 month waiting period for all treatment received unless the treatment was required as a result of an accident (external violent physical means).
No benefit shall be payable for the severe illness benefit if the Insured Person was diagnosed with Cancer (as defined) prior to the inception of this Policy.
This is not a Medical Scheme and the cover is not the same as that of a Medical Scheme.

Sub-limitation

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.

Our Ethics

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.