When looking at Gap Cover, it is important to not only see what they do have to offer, but take a look at when you are not covered with Gap Cover. It is often assumed by many that they will be covered for all of the extra costs incurred all of the time, however that is not always the case.
Take a look at the list below to see some of the times when you are not covered with Gap Cover:
When you have reached your annual aggregate limit of R158 000 per insured person per annum. (Except for the accidental death and policy extender benefits – This limit is subjected to regulatory amendment).
Where you have reached any of your benefit limits according to the maximum benefit insured i.e. the amount insured in respect of a Member, 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.
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.
Where you are claiming for a PMB procedure and your option does not cover this, or your option does cover it but the medical aid has not specified why they are not covering it in full.
Where you are claiming from the casualty benefit for treatment which is not an accident caused by an external force requiring immediate treatment e.g. no cover for any internal symptoms/illness.
Where your waiting periods as stipulated in the policy document are not completed.
This is not the full list of general exclusions. To find out more, contact your intermediary or download our full Terms and conditions here.
