Absolute cover plus

Applies to authorised in-hospital and in-lieu of hospital procedures, where the medical aid pays a portion of the fees from its in-hospital or major medical benefit. (Includes MRI/ CT/PET scans consumables.)

R5 250 per policy per annum.

Pain Relief Benefit – Provides cover for targeted pain relief treatment during surgery or following a severe trauma. This is covered even if the medical aid pays from day-today benefits or savings, provided the treatment forms part of an authorised in-hospital procedure, funded from the medical aid’s Risk or Major Medical Benefit: Unlimited but subject to the aggregate annual limit per insured person per annum.

Tariff Shortfall cover for service provider costs related to in-hospital mental health admissions requiring psychiatric care: 21 days.

A once-off lump sum from day 11 onwards for extended stays in a registered step-down or sub-acute care facility following hospitalisation: R12 000 per insured person per annum.

Cover for the shortfall on a specialist account related to the consultation in the rooms before a member is going for an in-hospital procedure.

Limited to the following number of consults p.p.p.a (up to a max of R500 per consult).

4 consults per policy per annum.

Sometimes accidents occur and you need to rush to casualty.

Your medical aid does not always cover the total costs in full. Whether payment comes from your medical scheme savings account or day-to-day benefit, the gap will be covered, provided it is for an ACCIDENT, and the treatment provided is at a casualty unit linked to a hospital.

Sometimes, your medical aid will not account for anything regarding this casualty visit, leaving you to cover the bill in full.
This benefit will cover you for up to R14 335 per policy per annum (subject to the annual limit*), EVEN IF YOUR MEDICAL AID COVERS NOTHING.

Children under the age of 8 ONLY – May be admitted for any treatment at a casualty unit linked to a hospital between the hours of 7 pm to 7 am from Monday to Friday, from 7 pm on a Friday until 7 am on a Monday, and all day on a public holiday.

Casualty follow-up consultations

(The initial treatment must have taken place in a casualty/ER unit linked to a hospital following an accident.) 

1 follow-up consultation per policy per annum at an ER unit (accident-related only).

The shortfall related to the use of Out-of-Network (Non-DSP) emergency medical services.

Unlimited but subject to the aggregate annual limit per insured person per annum.

These days most medical aid schemes impose a sub-limit on in-hospital prostheses costs and some even limit the monetary amount that is available for MRI and CT and PET scans. In both cases, members may be out of pocket and will have to cover these costs themselves.

• Prosthesis sub-limit: Unlimited but subject to R219 845 per insured person per annum. Up to R71 663 per event.
• MRI / CT / PET scans sub-limit: This benefit provides for 2 MRI, CT or PET scans per policy per annum and up to R6 615 per scan, subject to the annual limit*.
• Colonoscopies and Gastroscopies: This Benefit provides up to R24 225; per policy per annum. Up to R6 300 per event, subject to the annual limit.

• Accidents happen! Unfortunately, some severe accidents may even result in death. The situation is made worse if that person was the main breadwinner. Costs can run into the thousands and often funds are tied up to an estate.
• This benefit will provide an amount of R33 000 in the event of death of the insured and/or spouse, and R22 000 in the event of the death of the dependant, caused by violent, accidental, external, or visible means.

• Benefits: Home Drive, Uber, Panic Button (includes a Roadguard service), Medical Health Line & Trauma Counselling Line (including a COVID-19 care line) and Claims Submissions.
• Click here for more information.

• All TRA Gap Cover policyholders, under the age of 71, have access to the benefit of comprehensive travel insurance which you can read about HERE.
• Benefits include but are not limited to:
  • Emergency Medical and Related expenses: R1 000 000
  • Medical Evacuation, Repatriation or Transportation to a Medical Centre: Actual expense covered when arranged by Hepstar Financial Services.
  • Personal Accident Cover: Death: R25 000 / Permanent Disability: up to R25 000
  • Theft or Accidental Damage during trip: R5 000 / Single item limit: R1 500
  • Theft, Damage or loss by Airline: R5 000 / Single item limit: R1 500
  • Baggage Delay (more that 4 hours): R500
  • Baggage Delay (more that 24 hours): R1 000
• In addition, you may purchase a top-up plan by clicking HERE to increase your medical and baggage related cover, as well as add cover for trip cancellation, pre-existing medical conditions, missed connections and more.

  If you are a TRA policyholder, and you need eSIM services, you also have access to a unique link which will take you the SIMTEX website – there, you will Click “Get your eSIM” to purchase your eSIM and data. Your 20% discount will be applied upon checkout! Easy as that. To get your unique link, refer to your year-end email communications from TRA, or contact membership@totalrisksa.co.za.

• Unlimited per policy per annum but subject to R219 845
• These days most medical aid schemes insist that members pay an upfront amount for certain diagnostic and endoscopic procedures like gastroscopies and colonoscopies.
• This amount is known as a co-payment or deductible.
• The amount of times and total you can claim from this Co- Payment benefit is Unlimited (subject to the annual limit*), provided you make use of your medical aid’s designated service provider network.
• Where a policyholder voluntarily chooses to make use of a service provider that is NOT part of their medical aid’s designated service provider network, this benefit will be limited to 2 co-payment or deductible events per policy per annum, to a combined maximum of R17 640, subject to the annual limit*
• Co-Payment Benefit: Out of Hospital MRI/CT/PET scans. The co-payment or deductible that your medical aid charges you for MRI / CT / PET scans
  BUT which have been authorised and paid from the In-Hospital or Major Medical benefit. 2 scans per policy per annum. Unlimited but subject the aggregate annual limit per insured person per annum.

• Oncology Gap Benefit: Up to an aggregate of R219 845 per insured person per annum. The shortfall that arises after your medical aid has processed your account and is due to service providers charging above scheme tariff for medical aid approved oncology treatment plans (NB: Subject to the gap cover percentage; and medical aid approved treatment plan being covered up to scheme tariff and within annual scheme oncology limit).
• Oncology Gap Benefit: Breast Reconstruction Surgery; The shortfall that arises after your medical aid has processed your account and is due to service providers charging above scheme tariff for medical aid approved oncology related breast reconstruction surgery, including the unaffected breast. (NB: Subject to: the gap cover percentage; and medical aid approved treatment plan being covered up to scheme tariff and within the annual scheme oncology limit).  R38 588 per policy per annum

Oncology Co-Payment Benefit:

• The co-payment or deductible that your medical aid charges you for certain in-hospital procedures. This co-payment is NOT related to the scheme tariff and service provider charge shortfall or designated service provider arrangements.
• For claims where the medical aid will only pay a percentage for the approved treatment and the policyholder needs to pay the remaining percentage of the account.
• All costs to be within the annual scheme oncology limit.

Oncology Co-Payment Benefit (In Network): Unlimited per policy per annum but subject to R218 845 per insured person per annum.

Oncology Co-Payment Benefit (Out Of Network i.e. voluntary use of a non-designated service provider): 2 co-payments per policy per annum up to a combined limit of R17 640.

Oncology Extender Benefit: Includes ANY approved costs above annual scheme oncology limit but subject to the medical aid scheme covering up to this limit. Unlimited per policy per annum but subject to R219 845 per insured person per annum.

Oncology “New Tech” Benefit: We cover the shortfall / co-payment on new technology oncology treatment (specifically Keytruda®,Xalkori®, Tagrisso®, Yervoy®, Zelboraf®, Imbruvica®). Subject to a medical aid authorised treatment plan and designated service providers being utilised. Up to R18 191 per policy per annum

• We often hear of cases where one of our policyholders passes away, leaving their loved ones to pick up the pieces. They are left with the challenge to make sure that the gap cover they were used to is funded for a period of time.
• This benefit will provide for your gap cover premiums for a period of 12 months after the accidental death of the original policyholder.

• Where a global fee has been negotiated between a medical aid and service providers for a specific procedure (which includes ALL costs related to that procedure) and service providers charge amounts in excess of this global fee (not related to a tariff rate, co-payment or sub-limit).
• This benefit provides an amount of up to Up to R26 460 per policy per annum.

• Dental Benefit: Up to an aggregate of R219 845 per insured person per annum. The shortfall that arises after your medical aid has processed your account and is due to service providers charging above scheme tariff for authorised dental procedures performed in hospital or in doctor’s rooms and paid from the in-hospital or major medical benefit only.
• The cover is limited to a percentage of the original scheme tariff, as follows:
  • Adults and dependants over 18 years of age: Treatment of impacted wisdom teeth, extractions, apicoectomies or loss of teeth due to oncology or trauma ONLY.
  • Dependants up to 18 years of age: Any procedure or treatment.

The shortfall between the General Ward Rate and the Private Ward Rate for hospitalisation where an admission to a Private Ward occurred.

For Childbirth and for Non-Childbirth: Limited to a maximum of R2 205 per day, for a total of 3 consecutive days.

Provides cover towards a policyholder’s medical aid contribution in the case of the accidental death of the main policyholder. Cover is limited to the lower of the actual medical aid contribution or the maximum amount allowed. 6 months. Up to a max. of R7 275 per month.

Cover for the shortfall on a specialist (OBGYN/Paediatrician) account related to a consultation in the rooms within 6 weeks after childbirth. 

Up to R1 313 per consultation per policy per annum.

A fixed payout is provided in the event of a baby being born before 34 completed weeks of gestation (Excludes elective deliveries):   R20 000 per policy per annum.