When are you not covered?:
Co-payment Gap Cover (excluding Oncology Benefit):
• Where you have been charged a co-payment or deductible by your medical aid because you did not adhere to your medical aid rules or you chose to see a doctor or hospital that is not on your Scheme’s network. This is dependent on product choice
• Where your provider charged a separate fee (split billing) which you need to pay upfront and which cannot be claimed back from your medical aid.
• Where your treatment is related to Oncology, this co-payment does not apply at all.
Sub-limit cover:
• Where your medical aid sub-limit applies to any items besides MRI, CT or PET scans and internal prostheses. If your medical aid sub-limit is used up and your medical aid does not contribute any amount towards this account. Where your treatment is related to Oncology, this sub-limit benefit does not apply at all.
Casualty cover:
• Where the treatment is not an emergency / immediately required, is of an internal nature or did not come about due to an external force and/or impact with something or someone.
• Where the hospital charges for medication that is not part of an authorised procedure or that is taken home when being discharged.
• Where your medical aid covers casualty costs as part of a hospital benefit.Where your treatment is related to Oncology, this casualty benefit does not apply at all.
Oncology benefit:
• Where you want to claim for anything not related to Oncology under this benefit.
• Where your claim is related to Oncology treatment and you have reached any of your Oncology limits (see the Schedule), so you want to claim from the benefits which do not fall under the Oncology benefit e.g. Co-Payments.
• Where you have been charged a co-payment or deductible by your medical aid because you did not adhere to your medical aid rules or you chose to see a doctor or hospital that is not on your Scheme’s designated network.
• Where your provider charges a separate fee (split billing) which you need to pay upfront and which cannot be claimed back from your medical aid.
• Where your medical aid does not authorise treatment and/or biological medication as part of an approved oncology treatment plan.
• Where the Oncology costs are above scheme tariff (for the Oncology Gap Benefit applicable to all options) and the medical aid has not covered up to scheme tariff.
• Where the Oncology costs are above scheme tariff (for the Oncology Gap Benefit), or the Oncology costs are related to Oncology co-payments, and the treatment costs are not within the annual scheme oncology limit.
• Where the Oncology costs are above scheme limit (for the Oncology Extender Benefit) but the scheme has not covered up to this limit. (This is dependent on product choice).
Policy Extender Benefit:
• Where it is not related to the death of the Principal Policyholder who was paying the premium contributions for the Gap Cover Policy.
• Where the official documents i.e. the death certificate is not provided for.
• Where the benefit is not related to death.
• Where the premiums are to be provided for by TRA for a period of longer than 6 months.
Accidental Death Benefit:
• Where death does not occur within 12 months of the incident.
• Where death is caused, complicated or attributed to any of the following: – AIDS (Acquired Immune Deficiency Syndrome) – HIV (Human Immunodeficiency Virus) or any venereal disease – Use or suspected use of drugs or intoxicating liquor – Any self-inflicted event, including suicide or attempted suicide – Any wrongful or illegal action, including active participation in any riotous or such-like behaviour.
• Death while: – engaged in any form of military or police duties including reservist duties. – working in any mining or tunnelling operation. – Involved in any form of racing, other than by foot on solid ground, where there is an exceptional high risk.
• Non-compliance with Policy terms and obligations or not responding to our request for: – Medical examination. – Release of medical records and information. – Post-mortem examination or documents relating thereto, including death certificates. – Identification certificates.
