For TRA ?Gap Cover:

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? As with 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 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. Here are some points to help you to understand when you are not covered under your Gap Cover policy:

When you have reached the annual aggregate limit of R165 000 per policyholder per annum. (except for the accidental death and policy extender benefits - this limit is subject to regulatory amendment).

Where you and your dependants do not belong to a medical aid which is registered with the council for medical schemes.

Where you have reached any of your benefit limits according to the maximum benefit insured i.e. the amount insured in respect of a Policyholder, Spouse, Child or Dependant as stated in the Schedule.

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).

Where you have not been admitted into hospital - except for the Casualty benefit.

Where the dates of a claim are before or after the period you were admitted to hospital.

Where your hospital charges theatre and ward fees over and above medical aid rates.

MRI, CT and PET scans where your medical aid does not pay any portion of the account.

Where the hospital charges for medication that is not part of an authorised procedure or that is taken home when being discharged.

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 option choice.

Where the claim is below R100.

Where your claim is not related to Oncology, but you want to claim from the benefits which fall under the Oncology benefit e.g. Oncology Co- Payments - see the Schedule for your option benefits.

Where your claim is related to Oncology, but you want to claim from benefits which do not fall under the Oncology Benefit - see the Schedule for your option benefits.

Where you want to claim twice for one unique medical expense/ item from two benefits e.g. claiming a co-payment expense from the co-payment benefit as well as from the gap cover/shortfall benefit.

NB: where you have been charged any penalty by your medical aid because you did not adhere to your medical aid rules or you chose a doctor or hospital that is not on your scheme’s network

If you want to find out more on what you are covered for and what you are not covered for, speak to your intermediary or visit our website www.totalrisksa.co.za to find out more information.


Note: All material on this website is provided for your information only and may not be construed as medical advice or instruction. No action or inaction should be taken based solely on the contents of this information; instead, readers should consult appropriate health professionals on any matter relating to their health and well-being. The information and opinions expressed here are believed to be accurate, based on the best judgment available to the authors, and readers who fail to consult with appropriate health authorities assume the risk of any injuries. Errors and Omissions Excepted. Terms and Conditions Apply.