FAQ

No, the Ambledown Gap Cover Range augments (assists, increases) the benefit offered by a Medical Scheme. Regrettably without a recognised registered Medical Aid Plan in place as the Principal member or dependant you cannot have gap cover.

No, this product only covers immediate family which includes the spouse of the main member and children. Your parents may however take out their own policy.

Yes, an adult child will however need to take out his/her own gap cover policy, even if they are registered as a dependent on your Medical Scheme. However this is not applicable if the child, 26 years old or more is mentally or physically handicapped who is wholly dependent on you and is a registered dependent on your Medical Scheme. Proof of disability will be required.

Cover for the grandchild is subject to the child being legally adopted or fostered. Then the eligible child conditions will be applicable.

Certificate of insurance from the previous insurer will be required to prove cover. If there is no break in cover, cover will continue as is on the same benefits. Waiting periods will be imposed on any new benefits obtained and any unexpired waiting periods. The Insurer may also impose a 3 month general waiting period.

The Gap Cover Series is rated annually with adjustments taking effect on 1 January every year. Adjustments are based on various factors, including but not limited to, medical inflation, provider disposition (the likelihood of a medical practitioner to increase charges) as well as a study of the various Medical Scheme options and the impact on our product benefits. We do reserve the right to adjust the premium with 31 days written notice.

1. 1. 1. Any procedure not covered or declined by the Medical Scheme.
      2. Pre-existing conditions (Unless Waived).
      3. Depression, Insanity or mental stress or psychotic/psychoneurotic disorders.

It is recommended that a full list of exclusions be provided to the individual as per the policy wording.

Yes, should you buy-up in the range of products, new Waiting periods and pre-existing conditions will apply. The waiting periods and pre-existing conditions will apply to additional benefits.

No. Section 18 (1) of the Income Tax Act allows a deduction for contributions to a Medical Scheme registered in terms of the Medical Schemes Act of 1998. The Gap Cover Series is defined as Accident and Health products in the Short-Term Insurance Act.

That will depend on who the Policy Holder is and your company’s VAT registration conditions, kindly refer the query to your company Accountant or Tax Consultant.

The responsibility vests with you to ensure that the premium is paid and the debit order is collected successfully. Debit orders are collected electronically in advance. Should the debit order not be successful, the cover will be suspended on the last day of the month for which an unsuccessful debit was done. An automatic second debit will be run the following month which will include the arrears and the new month’s premium. Should the second debit not be successful, no further attempts will be made to collect arrear premiums and the policy will be effectively cancelled.

31 days written notice must be given to Ambledown via email to admin@ambledown.co.za or fax to (011) 463 1600. However, we do advise that you contact your broker to determine the necessity of the Ambledown Gap Cover product and submit the cancellation through the broker after proper consultation.

When the Regulator increases the Overall Annual Limit on Medical Expense Shortfall (Gap Cover)
benefits, will my limit be reset on the effective date (1 April), or will I only have the benefit of the
increased portion?

The Gap Cover policies administered by Ambledown run from 1 January to 31 December every year to ensure that your benefits align with the contract period of your medical aid. However, the Regulator publishes the new limit with an effective date of 1 April every year. This means that your limit will increase during the year and will not increase on 1 January when other changes become effective on your policy.

Ambledown makes provision for this change by stating, “The following Policy benefits are subject to an overall benefit limitation of R185,837, or any higher amount which may be published by the Regulator, in the aggregate per Insured Person per annum:”

This statement ensures that you automatically receive the benefit of the higher limit, which increased from R185,837 to R198,660.43 on 1 April 2023. To illustrate how this increase impacts your policy, it is best explained through the examples presented below.

– Your policy was renewed on 1 January 2023 with an overall annual limit of R185,837.
– Effective 1 April 2023, the limit increased to R198,660.43.
– For illustration purposes, we will assume that all the claims relate to one person covered under your policy. The limit is calculated separately for each insured person.

Example 1:

Claims between 1 January 2023 and 31 March 2023 amounted to R50,000. This would mean that between 1 April 2023 and 31 December 2023, you would have a balance available of R148,660.43 (R198,660.43 – R50,000).

Example 2:

Claims between 1 January 2023 and 20 March 2023 amounted to R155,000, and you have treatment on 22 March 2023 and claim R35,000, with the following outcome:
– An amount of R30,837.63 (R185,837.63 – R155,000) will be paid by the insurer.
– You would be liable for R4,162.37 (R35,000 – R30,837.63).
– For the balance of the year (1 April 2023 to 31 December 2023), you will have R12,822.80 available (R198,660.43 – R185,837.63) for any future claims.

Example 3:

If I have a claim as described in example 2, but I only submit my claim after 1 April 2023, will the policy pay the outstanding amount of R4,162.37 and reduce the available amount for the balance of the year by the same amount?

No, the insurer’s liability is determined on the date of the insured event/treatment date and not the date that the claim is received or notified. This is to make sure that the insurer is complying with the legislation.

The doctor’s account provides the diagnosis, date of service and procedure codes to be reviewed.   The medical aid statement *Claims Transaction History shows the processing of provider accounts and the scheme rules applied.

Click here to see examples of the Medical Aid Statement and the Doctors Account (DA)

Regrettably we do not provide pre-authorisations on claims. Please consult with you medical aid for such. Kindly refer to your gap cover policy document regarding your available benefits and applicable exclusions. Alternatively contact your broker to provide clarity where needed.

The claim will be considered if you have a Co-payment benefit on your policy.

However where the Co-payment is as a result of penalty imposed by your Medical Scheme, Gap cover will not reimburse you.

Where the Medical Scheme informs you of a Co-payment free option and you opt not to take it, such a “Co-payment” will be considered to be a penalty and such a claim will be rejected.

If the claim is within the benefit structure of the policy it will considered for payment. Where the accounts for the Specialist are declined by your Medical Scheme In part or in full, then it will not be considered for gap cover. This often occurs when the Specialist is not part of the Medical Aids’ Network of Providers (Designated Service Provider – DSP) and or operates in a hospital facility that does not belong to the Medical Aids’ Network of Listed Hospitals (Designated Service Provider – DSP).

Gap cover is not intended to cover you for the normal day to day benefits payable by your Medical Scheme, e.g. doctor consultations, medication, consumables. Generally (but not limited to) claims for procedures and treatment paid by your Medical Scheme out of your hospital risk benefits will be considered.

A claim form can be obtained from your broker or our website. It must be completed in full and emailed to claims@ambledown.co.za with all supporting documentation within 6 months of the first day of treatment / hospitalisation.

The principal member needs to provide his her own banking details for payment to be made. We do not pay the service provider.

The claim is assessed within a reasonable time frame from receipt of all supporting documentation. Our service levels require that a claims assessment be completed within 2 weeks of receipt of all supporting documentation.

A claim may be disputed by :

• Making representation to the Insurer indicated in the Disclosure Notice attached to the policy wording within 90 days of receipt of the benefit letter / rejection letter. The insurer is obliged to provide you with feedback within 45 days.
• You may also contact the Financial Services Ombud indicated in the Disclosure Notice attached to the policy wording should you not be satisfied with the response of the Insurer.
  • The FAIS Ombud may also be contacted for any complaints against your broker.
  • The Ombud for Short-Term Insurance or The Ombud for Long-Term Insurance may also be contacted for any complaints against the insurer.

You may also constitute legal action should the matter not be resolved by either the insurer or the relevant Ombud. The claim will prescribe 6 months after the expiry of the 90 day period indicated above. (No further claims will be payable for the specific claim)

The account will be considered if the treatment received was a result of an emergency or classified as an emergency treatment by the attending Medical Practitioner, as per the ICD codes on the invoices. Classification will not be limited to your interpretation of the symptoms presented.

The facility fee claims will NOT be covered as these are out-patient related claims. It is not related to an emergency to be considered for payment from the casualty benefit. Most of the charged items will relate to material expenditure, which is an exclusion on the policy.

Prescribed Minimum Benefits (PMB’s) are minimum benefits which by law must be provided to all Medical Scheme members by Medical Schemes and include the provision of diagnosis, treatment and care costs for:

1. • any emergency medical condition
   • a range of conditions as specified in Annexure A of the Regulations to the Medical Schemes Act (No 131 of 1998), subject to limitations specified in Annexure A. Included in this list of conditions is the list of chronic conditions.

This is what we refer to as “Split Billing”. Regrettably any amount charged by a Medical Practitioner or Hospital which is a separately identifiable fee, in excess of the Medical Scheme Tariff and not considered refundable by a Medical Scheme will not be considered under your gap cover. For gap to be assessed the account needs to reflect and be assessed by the Medical Scheme.