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Gap Cover:

Super Cover Plus

Our mid-range Gap cover Product

Super Cover Plus is our mid-range 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

R330 p/m

FAMILIES

R330 p/m

OVER 65’s

R490 p/m

The Super 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.

SUPER COVER PLUS

Benefits

SUPER 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 R13 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 internal prostheses costs. Members may be out of pocket and will have to cover these costs themselves

  • Prosthesis sub-limit: This benefit provides an amount of up to R11 000 per policy per annum, subject to the annual limit*.
  • This benefit provides for 1 MRI, CT, or PET scan per policy per annum, up to R3 600, subject to the annual limit*.
  • Colonoscopies and Gastroscopies: This benefit provides up to R13 000 per policy per annum. Up to R3 600 per event, subject to the annual limit*
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 R20 000 in the event of death of the insured and / or spouse, and R8 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.
CO-PAYMENTS

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
  • This benefit will cover you for up to R60 000 per policy per annum (subject to the annual limit*) for co-payment or deductible costs imposed by your medical aid, provided you make use of your medical aid’s designated service provider network.
  • Cover provided where a policyholder voluntarily chooses to make use of a service provider that is not part of their medical aid’s service provider network: 1 co-payment per policy per annum. Up to R5 000.
  • 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. 1 MRI / CT / PET scan per policy per annum up to
    R12 000.
Oncology

Oncology Gap Benefit: Up to an aggregate of R198 660 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). R18 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): Up to R60 000 per policy per annum.

Oncology Co-Payment Benefit (Out Of Network i.e. voluntary use of a non-designated service provider): 1 co-payment per policy per annum. Up to R5 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. Up to R35 000 per policy 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 R8 200 per policy per annum.

 

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
Global Fee Benefit

Where a global fee has been negotiated between a medical aid and service providers for a specific procedure e.g. robotic surgery (which includes ALL costs related to that procedure) and service providers charge mounts in excess of this global fee (not related to a tariff rate, co-payment or sub-limit).

Up to R12 000 per policy per annum.

Dental benefit

Dental Benefit: Up to an aggregate of R198 660 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, apicectomies or loss of teeth due to oncology or trauma ONLY.

Dependants up to 18 years of age: Any procedure or treatment.

Maternity Private Ward Benefit

The shortfall between the General Ward Rate and the Private Ward Rate, for hospitalisation for childbirth, where an admission to a Private Ward occurred. Limited to a maximum of R500 per day, for a total of 3 consecutive days.

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 R5 500 per month.

GET SUPER COVER PLUS NOW!*

*Annual Limit: The Basic Gap, Casualty and Oncology Gap benefits are subject to the aggregate gap cover annual limit of R198 660 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 .
Super Cover Plus - gap cover example

CERVICAL DISORDER

Sashnee saved R89 591.78. By choosing Super Cover Plus, you can too.

Your medical aid, just like Sashnee’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


Specialist Surgeon

Anaesthetist

Subtotal

Private Rate


R 118 420.34

R 12 673.87


R 131 094.21

Medical Aid Tariff


R 39 473.02

R 5 529.41


R 45 002.43

Gap Cover


R 78 947.32

R 7 144.46


R 86 091.79

Your Share


R 0

R 0


R 0

Medical Aid imposed co-payment (R 3 500.00)

Total

R 3 500.00


R 89 591.78

R 0


R 0

TERMS AND CONDITIONS APPLY

Woman wearing headphones and smiling

GAP COVER EXAMPLE

CERVICAL DISORDER

Sashnee saved R89 591.78. By choosing Super Cover Plus, you can too.

Woman wearing headphones and smiling

Your medical aid, just like Sashnee’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.

Super Cover Plus - Tariffs Payed
Super Cover Plus - Tariffs Payed

TERMS AND CONDITIONS APPLY

GAP COVER EXAMPLE

CERVICAL DISORDER

Woman wearing headphones and smiling

Sashnee saved R89 591.78. By choosing Super Cover Plus, you can too.

Your medical aid, just like Sashnee’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


Specialist Surgeon

Anaesthetist

Subtotal

Private Rate


R 118 420.34

R 12 673.87


R 131 094.21

Medical Aid Tariff


R 39 473.02

R 5 529.41


R 45 002.43

Gap Cover


R 78 947.32

R 7 144.46


R 86 091.79

Your Share


R 0

R 0


R 0

Medical Aid imposed co-payment (R 3 500.00)

Total

R 3 500.00


R 89 591.78

R 0


R 0

TERMS AND CONDITIONS APPLY

GAP COVER EXAMPLE

CERVICAL DISORDER

Woman wearing headphones and smiling

Sashnee saved R89 591.78. By choosing Super Cover Plus, you can too.

Your medical aid, just like Sashnee’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


Specialist Surgeon

Anaesthetist

Subtotal

Private Rate


R 118 420.34

R 12 673.87


R 131 094.21

Medical Aid Tariff


R 39 473.02

R 5 529.41


R 45 002.43

Gap Cover


R 78 947.32

R 7 144.46


R 86 091.79

Your Share


R 0

R 0


R 0

Medical Aid imposed co-payment (R 3 500.00)

Total

R 3 500.00


R 89 591.78

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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