You may have heard about our top Gap Cover product option, Absolute Cover Plus, but what is it all about?
Absolute Cover Plus is our flagship product which provides Gap Cover, Casualty cover, Co-Payment cover and Sub-Limit cover, as well as a separate Oncology benefit that provides Oncology Gap Cover, Oncology Co-Payment cover and Oncology Extender cover. 2020 has introduced two new and exciting benefits: The Global Fee Benefit and the Breast Reconstruction Surgery shortfall benefit. These benefits are subject to an overall annual limit of R165 000 per insured person per annum.
Basic Cover/Gap Cover:
Our Absolute Cover Plus option covers up to 700% above medical aid scheme tariff. This means that if your service provider charges anything up to 7 times what your medical aid will cover for in-hospital expenses, TRA will provide for this gap, subject to the annual limit.
Sometimes emergencies occur due to accidents and you need to rush to casualty. There are often times when 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. There is also the possibility that 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 R20 000 per policy per annum.
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 a 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 R14 000, subject to the annual limit.
Nowadays 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 R165 000 per insured person per annum. Up to R30 000 per event. MRI / CT / PET scans sub-limit: This benefit provides for 2 MRI or CT or PET scans per policy per annum and up to R4 000 per scan, subject to the annual limit.
The Oncology Gap Benefit:
Our Oncology Gap Benefit pays up to an aggregate of R165 000 per insured person per annum. This is for 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).
For 2020: 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). Up to R20 000 per policy per annum.
Oncology Co-Payment Benefit:
Oncology Co-Payment Benefit is unlimited per policy per annum but subject to R165 000 per insured person per annum. The co-payment or a 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 none arrangements, or 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. Please note that all costs to be within the annual scheme oncology limit.
The Oncology Extender Benefit:
Includes any approved costs above annual scheme oncology limit but subject to scheme covering up to this limit. Unlimited per policy per annum but subject to R165 000 per insured person per annum.
Global Fee Benefit:
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 R10 000 per policy per annum.
Accidental Death Cover: Our Absolute Cover Plus benefit will provide an amount of R10 000 in the event of death of the insured and / or spouse, and R5 000 in the event of the death of a dependant, caused by violent, accidental, external, or visible means.
Policy Extender: Should a policyholders pass away this benefit will provide for your Gap Cover premiums for a period of 6 months after the death of the original policyholder.
TRA Assist Mobile app: TRA also provides all Gap Cover policyholders with TRA Assist, which is powered by ER24 ASSIST. The benefits include a Home Drive service (which now includes access to Uber trips), a Panic Button and a Medical Health and Trauma Counselling Line.
To find out more information about TRA’s Gap Cover product options, contact your intermediary (who could give you advice on which Gap Cover product option to choose) or go to our website here.