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Gap Cover:

Vital Cover Plus

Our second entry level product

Vital Cover Plus is our second entry level product, which is sufficient in providing for Gap cover, Casualty cover, Co-Payment cover, Sub-Limit cover and a separate Oncology benefit that provides Oncology Gap cover and Oncology Co-Payment cover.

Premium Per Policy Per Month

INDIVIDUAL

R300 p/m

FAMILIES

R300 p/m

OVER 65’s

R450 p/m

The Vital 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.

VITAL COVER PLUS

Benefits

VITAL 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 the 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 R8 800 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 R5 500 per policy per annum, subject to the annual limit*.
  • No other sub-limits are included in this benefit.
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 R10 000 in the event of death of the insured and / or spouse, and
  • R5 500 in the event of the death of the dependent, 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.
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, apicoectomies or loss of teeth due to oncology or trauma ONLY.
    • Dependants up to 18 years of age: Any procedure or treatment.
Co-Payment
  • 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 R13 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.
  • NO cover is 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.
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 Co-Payment Benefit (In Network): Up to R13 000 per policy per annum
  • 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 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.
  • All costs to be within the annual scheme oncology limit.
  • Oncology Co-Payment Benefit (Out Of Network): No Benefit
  • Oncology Extender Benefit: No Benefit
  • Oncology ‘New-Tech’ Benefit: No Benefit
  • Oncology Gap Benefit – Breast Reconstruction Surgery: No Benefit
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 R4 400 per month.

Travel Benefit
  • 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.

GET VITAL 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 .
Vital Cover Plus - gap cover example

SPINAL SURGERY

Ezra saved R 74 569.15. By choosing Vital Cover Plus, you can too.

Your medical aid, just like Ezra’s, may not cover 100% of the private rate of the medical practitioner, resulting in a shortfall payment due from you.

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

Attending Doctor


Orthopaedic Surgeon

Specialist Anaesthesiologist

Private Rate


R 135 269.03

R 42 516.76


R 177 785.79

Medical Aid Tariff


R 87 464.90

R 14 343.06


R 101 807.96

Gap Cover


R 47 804.13

R 26 765.02


R 74 569.15

Your Share


R 0

R 0


R 0

TERMS AND CONDITIONS APPLY

Man wearing a backpack

GAP COVER EXAMPLE

SPINAL SURGERY

Ezra saved R 74 569.15. By choosing Vital Cover Plus, you can too.

Man wearing a backpack

Your medical aid, just like Ezra’s, may not cover 100% of the private rate of the medical practitioner, resulting in a shortfall payment due from you.

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

Vital Cover Plus - Tariffs Payed

TERMS AND CONDITIONS APPLY

GAP COVER EXAMPLE

SPINAL SURGERY

Man wearing a backpack

Ezra saved R 74 569.15. By choosing Vital Cover Plus, you can too.

Your medical aid, just like Ezra’s, may not cover 100% of the private rate of the medical practitioner, resulting in a shortfall payment due from you.

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

Attending Doctor


Orthopaedic Surgeon

Specialist Anaesthesiologist

Private Rate


R 135 269.03

R 42 516.76


R 177 785.79

Medical Aid Tariff


R 87 464.90

R 14 343.06


R 101 807.96

Gap Cover


R 47 804.13

R 26 765.02


R 74 569.15

Your Share


R 0

R 0


R 0

TERMS AND CONDITIONS APPLY

GAP COVER EXAMPLE

SPINAL SURGERY

Man wearing a backpack

Ezra saved R 74 569.15. By choosing Vital Cover Plus, you can too.

Your medical aid, just like Ezra’s, may not cover 100% of the private rate of the medical practitioner, resulting in a shortfall payment due from you.

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

Attending Doctor


Orthopaedic Surgeon

Specialist Anaesthesiologist

Private Rate


R 135 269.03

R 42 516.76


R 177 785.79

Medical Aid Tariff


R 87 464.90

R 14 343.06


R 101 807.96

Gap Cover


R 47 804.13

R 26 765.02


R 74 569.15

Your Share


R 0

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.

OUR LATEST NEWS

6 February 2024News, TRA News

The Best Gap Cover in South Africa: Going The exTRA Mile for their Clients

Gap cover has become an essential safeguard against unforeseen medical expenses for South Africans. With so many options available, understanding

18 January 2024News, TRA News

TRA’s Support for Out-of-Hospital Procedures

Total Risk Administrators (TRA) is committed to offering comprehensive gap cover for various out-of-hospital procedures. The following article expands on

Read More
8 January 2024News, TRA News

TRA’s Gap Cover Exclusion Policy

Policyholders need to understand that having medical aid does not guarantee that your insurer will cover all of your medical

Read More