Introducing you to

Tariff Shortfalls: Shortfalls on medical specialists while in hospital

Limited to an additional five times (500%) that of the medical scheme tariff. Examples of in-hospital events:

• Childbirth
• Dentistry (basic)
• Tonsillectomy (Tonsil removal)
• Broken bones
• Gynaecological procedures
• Scopes: gastroscopies & colonoscopies
• Orthopaedic surgery
• Cardiac surgery

Sub-Limits *Summit Plan only:
Medical Schemes often put limits on certain procedures. This means, they will only pay up to a defined rand value, however, your treatment may cost more. We will cover you up to a limited amount per year.
Examples of such procedures:

• Internal Prosthetics
• Pacemakers
• Implants
• Joint replacements

Co-payments on Listed Treatments: These are defined amounts that you need to pay upfront (as per your Medical Scheme) to the hospital, which you can claim back from Gap cover. This pertains to:

• Scopes
• Wisdom tooth extractions
• Back and neck treatment
• Reflux surgery

Penalties may be applied for using a hospital outside of your Medical Scheme network, we cover these penalty co-payments up to a rand limit per annum

For more information on the full policy benefits and limits for your preferred plan option – click here

Co-payments on Listed Treatments: These are defined amounts for procedures that you need to pay upfront (as per your Medical Scheme) to the service provider, which you can claim back from Gap cover. This pertains to:

Diagnostic radiology to find the problem:

• MRI Scans
• CT Scans
• Arthroscopy

Other treatments include but not limited to:

Defined Medical Procedures
Conservative Back and Neck Treatment	In-patient Basic Dentistry
Myringotomy	Endometrial Ablation
Tonsillectomy	Hernia Repair
Adenoidectomy	Varicose Vein Surgery
Facet Joint Injections	Percutaneous Radiofrequency Ablations
Arthroscopy	Rhizotomies
Functional Nasal Procedures	Circumcision
Non-Malignant Hysterectomy	Hymenotomy
Laparoscopy	Nissen Fundoplication
Confinement	Spinal Fusion or Major Joint Replacement
Hysteroscopy

For more information on the full policy benefits and limits for your preferred plan option – click here

*Summit Plan only

Oncology (Cancer Treatments): We cover a variety of cancer related treatments (when your treatment plan has been reviewed and approved by your Medical Scheme):

• 20% Co-payment applied when you reach your cancer limit defined in your Medical Scheme plan
• The difference between what your cancer specialist charges and what your Medical Scheme pays
• A lump sum payment when you are first diagnosed with cancer and your treatment plan has been approved, up to the age of 66 years

For more information on the full policy benefits and limits for your preferred plan option – click here

• Accidental Death and Disability: If you, or one of your dependants pass away or becomes permanently disabled as a result of an accident, we will pay R20 000 for children under 6 years old and between R28 000 and R30 000 for all other people covered on the policy.
• Contribution Waiver: If the main member of your Medical Scheme passes away as a result of an accident, we will cover your Medical Scheme contributions for a limited period and amount. We will also waive your Gap Cover premium for 6 months.

For more information on the full policy benefits and limits for your preferred plan option – click here