We cover a list of exclusions in the upcoming series. It’s important to note that gap cover is not
designed to cover shortfalls in your day-to-day medical expenses but your major medical procedures.

1. General 3 months waiting period? 
   A general 3 months waiting period is applied to all new policies. Accident claims are covered from the inception of the policy and are not subject to any waiting periods. Always check your policy document as exclusions are dependent on your Gap cover provider.
2. 12 months waiting period for pre-existing conditions
   A 12 months pre-existing condition waiting period will be applied. This is only valid for the first 12 months of the Gap cover policy. Cover will exclude an incident, even though it falls within the scope of the policy, if it relates to treatment or advice received in the 12 months prior to the policy coming into effect.
3. Cosmetic surgery and specific mental conditions
   Treatments that are excluded from most Gap cover policies include cosmetic surgery, drug and alcohol addiction, suicide, and mental conditions, including depression, insanity, mental or mental stress, psychotic / psychoneurotic disorders, behavioural and neurodevelopmental disorders.
4. Infertility treatments
   Treatments and investigations relating to artificial insemination or hormone treatment for infertility are not eligible for Gap cover. But, some of these conditions are covered by the medical scheme.
5. Precautionary diagnostic procedures
   Routine procedures such as cholesterol and blood pressure tests incurred purely as a precaution and not related to an impairment are not covered by a gap cover policy. Diagnostic procedures prompted by a health condition are covered depending on your Gap provider. Key precautionary diagnostic procedures would generally be covered from your Medical Savings Account. Individuals need to check the precise details with their medical scheme.
   
6. Prescribed minimum benefits (PMBs)
   Prescribed Minimum Benefits are conditions gazetted by the Minister of Health and require medical schemes to provide cover in full. They include emergency medical assistance, 271 medical conditions and 26 chronic conditions. Therefore, by implication, PMBs are not covered by Gap cover.
7. Hospitalisation expenses related to hospitalisation
   All ward and theatre fees, medicines, costs for materials such as gloves and the like, and any other hospital expenses strictly related to hospitalisation are generally excluded. The fees charged by specialists such as surgeons and anaesthetists do qualify for Gap cover.

 

A reminder that Gap cover is not a substitute for medical scheme membership and the cover is not
the same as a medical scheme. Gap cover is only available to members of a medical scheme. It is
designed to limit the out-of-pocket medical expenses not covered in full by the medical scheme.
Products are designed to cover major medical events in hospital and specific out-patient treatment
and procedures.

 

For more information and to find a gap cover solution to suit your specific needs, go to www.ambledown.co.za/gap-cover-series.