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Frequently Asked Questions

The gap is covered in instances where there is a shortfall between what service providers charge and what your medical scheme will cover for in-hospital expenses.

Like most people, you have a medical aid to give you peace of mind that if you need medical care for any reason – be it through accident or illness – your bills will be taken care of. After all, who needs to add financial worry to the stress of being hospitalised? And… like most people, you probably assume that if you have a medical aid, then you’re 100% covered. Unfortunately, this is not always true – which is why you need TRA gap cover to ensure that you don’t receive a huge bill if there’s a shortfall between what the doctors charge and what your medical aid will pay for in-hospital procedures.

All of our TRA Gap Cover Policies:

  1. Provide benefits for a policyholder and their spouse and those financially dependent on them (child/children and/or aged parents) who are covered on one policy of a registered medical aid scheme. Subject to proof of membership and the premium being based on the age of the oldest beneficiary. Members and their dependants can also be on two different medical aids and one Gap Cover Policy but only if they are legally married, or common law partners verified by submission of an affidavit confirming 12 months of cohabitation.

  2. Have no entry age limit.

Our TRA Gap Cover policies range in price, starting at just R99 per policy per month. You can compare all of our product option benefits and pricing on the information table on our Gap Cover page.

Claims - Manual and Automatic Processes

It remains the policyholder’s responsibility to ensure that Claims are submitted to and are received by TRA within six (6) months from the date of treatment, as well as ensuring That TRA has the correct banking details into which the Claim must be paid.

Claims - Manual Process

Policyholders need to submit the following:

  • Claim from the Service Provider.

  • First TWO (2) pages of the hospital account showing the admission and discharge dates of the hospital event.

  • The Medical Aid statement showing the payment of the Service Provider claim and reason for short payment.

  • Claim documents can be emailed to claims@totalrisksa.co.za, submitted online via our website www.totalrisksa.co.za or submitted via our mobile app, TRA Assist. Alternatively, TRA may be contacted directly on +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 not necessary for the Policyholder to submit their claim to TRA. TRA will receive an electronic version of the claim and will process said claim within seven (7) 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 for additional information (e.g. Pre-authorisation letter, medical aid statement, doctor’s Account or first 2 pages of the hospital account) is not received, all the additional information must be submitted to TRA within 30 days from the date of request or the claim will be rejected as late/stale in terms of this policy and will not be paid.

All of our TRA Gap Cover Policies:
Are not medical aid schemes. The cover is not the same as that of a medical aid scheme. The cover is not a substitute for a medical scheme membership.

Gap Cover :
The shortfall that arises after your medical aid has processed your account and is due to service providers charging above scheme tariff for authorised in-hospital procedures. The cover is limited to a percentage of the original scheme tariff.

When are you not covered under your Gap Cover policy?:

Where your medical aid does not pay their portion of an account first from the Risk or Major Medical benefit. No claims processed from your Scheme’s day to day benefit will be covered - except for the Casualty benefit. (Please check your option benefits in the Schedule).