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 bills. Sometimes, you may need to pay an extra amount, which is known as a shortfall. In such situations, if the medical treatment is included, a gap cover policy in addition to your medical aid is beneficial.

It is important to remember that Gap Cover policies still have exclusions detailed in their policies.

This article highlights TRA’s Gap Cover Exclusions, allowing for further understanding of your TRA policy.

TRA Medical Gap Cover Exclusion Policy

You are excluded from cover by your Gap Cover policy when:

1. The annual aggregate limit of R198 660 (subject to increase in April 2024) per policyholder per annum has been reached, except for accidental death and policy extender benefits, which are subject to regulatory amendment.
2. You and your dependents do not belong to a medical aid registered with the council for medical schemes.
3. Any benefit limits according to the maximum benefit insured have been reached, i.e. the amount insured for a policyholder, spouse, child, or dependent.
4. 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.
5. You have not been admitted to a hospital except for the Casualty benefit.
6. The dates of a claim are before or after the period you were admitted to the hospital.
7. The hospital charges theatre and ward fees over and above medical aid rates.
8. MRI, CT, and PET scans, where your medical aid does not pay any portion of the account.
9. The hospital charges for medication that is not part of an authorized procedure or taken home when discharged.
10. Your medical aid has charged you a co-payment or deductible because you did not adhere to your medical aid rules or chose to see a doctor or hospital not on your scheme’s network. This is dependent on product option choice.
11. The claim is below R100.
12. Your claim is unrelated to Oncology, but you want to claim from the benefits that fall under the Oncology benefit, e.g., Oncology Co-Payments. See the Schedule for your option benefits.
13. 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.
14. 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.
15. NB: where your medical aid has charged you any penalty 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 learn more about your coverage, please get in touch with your intermediary or visit our website.

Understanding Your Policy Will Save the Day

It is crucial to acknowledge that medical aids have limits, which is where Gap Cover bridges the financial gap.

However, it is equally important to acknowledge that Gap Cover also has its exclusions and limitations. Understanding these exclusions is essential to make an informed decision about healthcare coverage.

Remember that Gap Cover is meant to complement your medical aid, not replace it.

Consult with a knowledgeable intermediary or visit our website for more information. Choose a Gap Cover policy that aligns with your healthcare needs. Ensure that you’re adequately prepared to handle any medical financial challenges that may arise.