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Gap Cover:

Absolute Cover Plus

Our flagship Gap Cover Product

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.

Premium Per Policy Per Month

INDIVIDUAL

R590 p/m

FAMILIES

R590 p/m

OVER 65’s

R730 p/m

The 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, TRA will provide for this GAP, subject to the annual limit.

Absolute Cover Plus

Benefits

Absolute Cover Plus

Benefits

CASUALTY
  • 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 R22 000 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
SUB-LIMIT

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 R210 580 per insured person per annum. Up to R65 000 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 000 per scan, subject to the annual limit*.
  • Colonoscopies and Gastroscopies: This Benefit provides up to R22 000 per policy per annum. Up to R6 000 per event, subject to the annual limit.
POLICY EXTENDER
  • 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.
Medical Aid Contribution Waiver Benefit

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 R6 600 per month.

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 R24 000 per policy per annum.
MATERNITY PRIVATE WARD

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

  • This benefit is limited to a maximum of R2 000 per day, for a total of 3 consecutive days.
CO-PAYMENTS
  • Unlimited per policy per annum but subject to R210 580
  • 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 R16 000, 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
  • Oncology Gap Benefit: Up to an aggregate of R210 580 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).  R33 000 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 R210 580 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 R16 000.

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 R210 580 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 R16 500 per policy per annum

ACCIDENTAL DEATH
  • 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 R30 000 in the event of death of the insured and/or spouse, and R20 000 in the event of the death of the dependant, caused by violent, accidental, external, or visible means.
TRA ASSIST
  • Benefits: Home Drive, Uber, Panic Button, Medical Health Line, Trauma Counselling Line (including a COVID-19 care line) and Claims Submissions.
  • Click here for more information.
TRAVEL BENEFIT
  • Benefits include but are not limited to:
    • Emergency Medical and Related expenses: R600 000. Excess R500.
    • COVID-19 Extension: Emergency inpatient or outpatient treatment due to COVID-19 R600 000.
    • Medical evacuation, repatriation or transportation to a medical centre – FULL COST covered when arranged by Hepstar.
    • Hospital Cash benefit R500 per day (max R3 000).
    • Inconvenience Cover: Baggage Cover: R5 000 for theft, damage or loss by travel supplier.
DENTAL BENEFIT
  • Dental Benefit: Up to an aggregate of R210 580 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.

GET Absolute Cover Plus NOW!*

*Annual Limit: The Basic Gap, Casualty and Oncology Gap benefits are subject to the aggregate gap cover annual limit of R210 580 per insured person per annum. (This limit may change due to regulatory amendment).

A full list of 2024 terms and conditions can be viewed here .
Absolute Cover Plus - gap cover example

PLACEMENT OF INTERNAL PROSTHESIS

Judy saved R110 316.11. By choosing Absolute Cover Plus, you can too.

Your medical aid, just like Judy’s, may impose a co-payment on Endoscopic or Laporoscopic Procedures, Hysterectomies as well as Colonoscopies.

Eliminate the financial worry from the stress of a hospital operation or stay.

Attending Doctor


Orthopaedic Surgeon

Anaesthetist

Subtotal

Private Rate


R 121 227.71

R 27 642.94


R 148 920.65

Medical Aid Tariff


R 39 143.44

R 11 998.10


R 51 141.54

Gap Cover


R 82 134.27

R 15 644.84


R 97 779.11

Your Share


R 0

R 0


R 0

Medical Aid Sub Limit for Internal Prosthesis

Medical Aid Sub Limit for Internal Prosthesis

Total

R 42 537.00


R 148 920.65

R 30 000.00


R 51 141.54

R 12 537.00


R 110 316.11

R 0


R 0

TERMS AND CONDITIONS APPLY

Elderly lady smiling

GAP COVER EXAMPLE

PLACEMENT OF INTERNAL PROSTHESIS

Judy saved R110 316.11. By choosing Absolute Cover Plus, you can too.

Elderly lady smiling

Your medical aid, just like Judy’s, may impose a sub-limit fee for Hip or Knee Replacements, as well as Pacemaker and Stent Operations.

Eliminate the financial worry from the stress of a hospital operation or stay.

Absolute Cover Plus - Tariffs Payed
Absolute Cover Plus - Tariffs Payed

TERMS AND CONDITIONS APPLY

GAP COVER EXAMPLE

PLACEMENT OF INTERNAL PROSTHESIS

Elderly lady smiling

Judy saved R110 316.11. By choosing Absolute Cover Plus, you can too.

Your medical aid, just like Judy’s, may impose a sub-limit fee for Hip or Knee Replacements, as well as Pacemaker and Stent Operations.

Eliminate the financial worry from the stress of a hospital operation or stay.

Attending Doctor


Orthopaedic Surgeon

Anaesthetist

Subtotal

Private Rate


R 121 227.71

R 27 642.94


R 148 920.65

Medical Aid Tariff


R 39 143.44

R 11 998.10


R 51 141.54

Gap Cover


R 82 134.27

R 15 644.84


R 97 779.11

Your Share


R 0

R 0


R 0

Medical Aid Sub Limit for Internal Prosthesis

Medical Aid Sub Limit for Internal Prosthesis

Total

R 42 537.00


R 148 920.65

R 30 000.00


R 51 141.54

R 12 537.00


R 110 316.11

R 0


R 0

TERMS AND CONDITIONS APPLY

GAP COVER EXAMPLE

PLACEMENT OF INTERNAL PROSTHESIS

Elderly lady smiling

Judy saved R110 316.11. By choosing Absolute Cover Plus, you can too.

Your medical aid, just like Judy’s, may impose a sub-limit fee for Hip or Knee Replacements, as well as Pacemaker and Stent Operations.

Eliminate the financial worry from the stress of a hospital operation or stay.

Attending Doctor


Orthopaedic Surgeon

Anaesthetist

Subtotal

Private Rate


R 121 227.71

R 27 642.94


R 148 920.65

Medical Aid Tariff


R 39 143.44

R 11 998.10


R 51 141.54

Gap Cover


R 82 134.27

R 15 644.84


R 97 779.11

Your Share


R 0

R 0


R 0

Medical Aid Sub Limit for Internal Prosthesis

Medical Aid Sub Limit for Internal Prosthesis

Total

R 42 537.00


R 148 920.65

R 30 000.00


R 51 141.54

R 12 537.00


R 110 316.11

R 0


R 0

TERMS AND CONDITIONS APPLY

FREQUENTLY ASKED QUESTIONS

What is Gap Cover?​

Gap Cover is an insurance policy that covers the difference between what your medical aid pays and what service providers charge for in-hospital expenses.

 

How do I claim from Gap Cover?

Claims – Manual and Automatic Processes

The policyholder is responsible for ensuring that claims are submitted and received by TRA within six (6) months from the treatment date. The policyholder should also ensure that TRA has the correct banking details into which we must pay the claim.

 

Claims – Manual Process

Policyholders need to submit the following:

  • The claim from the service provider.
  • The first two pages of the hospital account that show the hospital event’s admission and discharge dates.
  • The medical aid statement showing the payment of the service provider claim and the reason for the short payment.
  • You can email these claims documents to claims@totalrisksa.co.za or submit them via our website, www.totalrisksa.co.za or our mobile app, TRA Assist.
  • Alternatively, you can contact TRA directly at +27 (11) 372 1540. One of our highly qualified and friendly claims specialists will gladly assist.

 

Claims – Automatic Process

TRA receives claims submitted by selected medical aid schemes on behalf of the policyholder. Should your medical aid company have such an agreement with TRA, it is optional for the policyholder to submit their claim to TRA.

 

TRA will receive an electronic version of the claim and will process the said claim within seven working days of receipt thereof.

 

Co-payment and sub-limit claims must always be submitted manually by the policyholder (in addition to all the required claims documentation, please also provide proof of any direct payment/s made to these service providers).

 

Should a claim be rejected because additional information (e.g. pre-authorisation letter, medical aid statement, doctor’s account or the first two pages of the hospital account) is not received, all the information must be submitted to TRA within 31 days from the date of the request or the claim will be rejected as late/stale in terms of this policy and will not be paid.

Why do I need Gap Cover?

Most people purchase medical aid and assume they will take care of all their medical bills. Unfortunately, this is not always true. Medical shortfalls can occur if you need medical care for any reason – accident or illness. You don’t want to add financial worry to the stress of being hospitalised, which is why you need Gap Cover.

 

Gap Cover ensures you don’t receive a massive bill if there’s a shortfall between what the doctors charge and what your medical aid will pay for in-hospital procedures.

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