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WHY DO I NEED

GAP COVER?

Private healthcare is expensive. Many people believe that if they are on a premium medical aid scheme, all their medical expenses will be covered. Sadly, this isn’t the standard scenario. Your medical aid will not always cover all your in-hospital costs. The reality is that most medical aids only cover 100% of the medical practitioner’s costs; however, practitioners can charge anything up to 500% above the standard medical aid rate. Medical aid gap cover is a medical expense shortfall which fills the gap between what is covered by your medical aid, and the actual costs incurred during in-hospital procedures.

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COMPARE OUR PLANS

Compare our plans and simply request a call back. We’ll explain all the benefits and help select the right plan for you. Alternatively, you can request an online quote now.

THE BENEFITS EXPLAINED

Coverage
Covers the medical practitioner cost for in-hospital procedures and specified outpatient procedures. Cover is limited to the percentage of the Medical Scheme Tariff and does not provide for additional costs of prosthesis, materials and medication. It covers the services provided by specialists, general practitioners and medical professionals during the period of hospitalisation.

Casualty Benefit
If you receive emergency medical treatment in a hospital casualty unit, this benefit will cover the treatment costs. Limited to R10, 000 per insured person per annum.

“Emergency” means the sudden and, at the time, unexpected onset of a health condition requiring immediate medical treatment and/or 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.

Sub-limitation
This covers you for charges above most limits for in-hospital procedures and treatment which exceeds limitations imposed by the medical scheme.

The Medical Aid Scheme sets sub-limits on Medical Aid benefits. These limits can be set per procedure type in order to manage exposure.

Co-payment
If you are required to pay an upfront fee, before medical assistance is administered (e.g. MRI scan), co-payment can help you cover the cost.

“Co-Payment” means a stated amount imposed as a co-payment or deductible by a medical scheme. A co-payment or deductible must be indicated in the rules of the medical scheme as approved by the Council for Medical Schemes.

A co-payment or deductible as a result of an agreement between a member and a medical scheme will not qualify for benefits in terms of this policy.

Premium Waiver

In the event of the total and permanent disability of the principal member of the medical scheme due to an accident, the benefit will pay the medical aid premiums at the time of the incident for six months within the stated limitations. This benefit will commence on the first day of the following month from the date of the incident.

The Premium Waiver Benefit terminates at the earlier of the member reaching the benefit expiry age of sixty-five. Claims submitted before the benefit expiry age will be assessed and paid, but claims after the benefit expiry age will not be accepted. The Premium Waiver Benefit is not available on the Senior package.

Oncology
This benefit provides cancer treatment in a private hospital subject to the sub-limitations and co- payments imposed by the medical scheme and covers charges for treatment subject to a defined list of biological Cancer drugs for specific oncological conditions and/or sub-groups of cancer.

This benefit provides for Cancer treatment in a private hospital subject to an excess of R200,000 per Treatment Cycle.

Treatment includes hospital expenses, chemicals, medication and out-patient radiotherapy or chemotherapy and excludes the cost of specialist consultations.

Hospital Excess Cover
Covers the excess amount which exceeds the limitations applicable under the Medical Aid option and/or above the hospital limitation. Hospital Excess Cover is subject to a minimum excess of R200,000.

Limits
All benefits are limited to R198,660 per insured person per annum.

Crisis Centre
State-of-the-art crisis management centre, available 24 hours a day, 7 days a week. Provides expert crisis assistance and emergency co-ordination for all services as well as public services.

Call a GP or Nurse
The 24 hour GP helpline is staffed by medical professionals. This critical service provides advice and assistance. Members will be able to discuss a number of medical related matters with a qualified GP and or nurse on the following: medical advice, second opinion, confirmation and clarity of medical diagnosis, guidance on drug regime, guidance to a specialist GP, guidance and advice on the side effects of prescribed treatment, telephonic follow up after diagnosis and treatment.

C5 HIV Prevention Programme
In the event that a policyholder is exposed to HIV through a trauma or assault, the member will have access to: 24 hour Telephonic HIV advice and counselling line, emergency evacuation to HIV treatment facility (ER24 only), medical consultation, 3 day starter pack, 25 day antiretroviral HIV treatment including, sexually transmitted disease therapy and pathology tests.

Trauma Counselling
In the event that a member is involved in a traumatic event or is witness to a traumatic event the member will have access to unlimited telephonic counselling, referral to a qualified counsellor, face to face counselling with a qualified counsellor.

Limited to R3,000 per event.

Household Assistance
Provides Elixi Gap Cover members with a callout and up to one hour’s labour (initial fault only), for emergency events that relate to plumbing, electrical faults, faults with appliances, damage to external windows, and emergencies where a locksmith is required.

FEATURED REVIEWS

OUR PARTNERS

In order to deliver on our promise to you, we have partnered with Guardrisk and Ambledown who not only share our values and vision, but also our passion for ensuring that every South African is given the opportunity to access quality, private healthcare.

For more info, click link below:

This is NOT a medical scheme and will not be a substitute for
medical scheme membership. It fills the GAP between what
is covered by your medical aid, and the actual amount
charged by your medical practitioner for in-hospital
procedures.