Gap Cover - Summit Plan

Tariff Shortfalls

Cover the difference between what your specialist charges and what the medical scheme pays according to their rate. Limited to an additional (600%) that of the medical scheme tariff. 

 

Examples of Procedures: (in-hospital)

• Childbirth
• Dentistry (basic)
• Tonsillectomy (tonsil removal)
• Broken bones

Examples of procedures covered out of hospital:

• Gastroscopy, cystoscopy or hysteroscopy
• Dialysis treatment
• Home births
• Circumcision
• Root canal

Read more – Policy Documents

Standard Co-Payments and Deductibles

These are defined amounts that you need to pay upfront (as per your medical scheme) to the hospital, which you can claim back.

 

In-Hospital examples include:

• Scopes
• Pacemakers
• Implants

Out-of-Hospital examples include:

• MRI scans
• CT scans
• PET scans
• Scopes

 

Benefits limited to the Core Benefit Limit.

Read More: Policy Documents

Sub-Limits

 

Medical schemes often put limits on certain procedures. This means they will only pay up to a defined value, however, your treatment may cost more. We will cover you up to R64 500 per event. This benefit is subject to Core Benefit Limit.

 

Examples of such procedures:

• Internal prosthetics
• Pacemakers
• Implants
• joint replacements

 

Read More: Policy Documents

Oncology First Time Diagnosis

 

This lump sum benefit has been included in your cover for 2024. For the first-time diagnosis of cancer to the medical equivalent of stage 2 or higher form of cancer. The benefit is only payable during an Insured Event. It excludes any form of cancer that was previously identified or required Treatment. It excludes cancer diagnosed prior to 2024. The Benefit will be limited to R15 000 per Insured Party, and one claim per Insured Party for the lifetime of the Policy

Oncology (Cancer) Benefits

 

Oncology Tariff Shortfalls: covers you for shortfalls in respect of cancer related Treatment, approved by the medical scheme, limited to an additional 500%.

Oncology Sub-Limits: cover for when the charges relating to the services supplied, have exceeded the benefit sub-limit that applies to cancer treatment of the medical scheme plan type you are on.

Oncology Co-payments: cover for the co-payment applied once your cancer related costs have exceeded the specific threshold defined by your medical scheme. Limited to 20% of your co-payment amount.

Innovative Oncology Medicines: cover for defined innovative oncology medicines which have been approved by your medical scheme. Limited to the lesser of 25% of the total drug cost or R13,780.

 

Read More: Policy Documents

Dental Reconstruction Benefit

 

The benefit is for dental reconstruction surgery that is required as a direct result of either accidental harm or oncology treatment. It covers the difference between what the specialist charged and the medical aid paid.

 

Limited to 2 events per family and annually and a maximum of R49 900. Subject to Core benefit limit.

 

Read More: Policy Documents

Accidental Casualty & Child Casualty

 

Covers you and your family in an accidental emergency or for children under 12 for illness relate emergencies. If payment is made from your available medical savings account, or from your own pocket, we will reimburse that too.

 

Examples of Accidental Harm are:

• • Broken bones
  • Falls
  • Cuts

 

Cover is limited to R18 450 for Accidental Casualty and R2 860 for Child Casualty.

 

Limits apply: Policy Documents

Lump sum payments: 

In the event of accidental death or permanent disability due to an accident, with these limits:

• Children below six years: R20 000
• All other Insured Parties: R30 000

Contribution Waiver:

Your medical scheme contributions will be covered for 6 months up to a maximum of R35 500 where policyholder is the principal member of the medical scheme.

 

Read More: Policy Documents

Maternity Extender – Family booster

 

A lump sum benefit is payable when a premature birth occurs.

The Lump Sum payable is R15 900.

 

Read more: Policy Documents

Hospital Booster

Lump-Sum payments & Contribution Waiver

Daily lump sum benefits are paid when an insured party is admitted to a hospital, because of accidental injury or premature birth.

 

A maximum of two hospital episodes are covered under this benefit R29 300 Per family/per annum.

 

The benefit is payable from day one of the hospital episode:

R480 per day from the 1st – 13th day (inclusive).

R860 per day from the 14th – 20th day (inclusive).

R1 700 per day from the 21st – 30th day (inclusive).

 

Read More: Policy Documents

Lifestyle Benefits

Part of the Lifestyle Benefits at R55 | policy 

 

• Counselling from health professionals – unlimited telephonic, virtual or face-to-face appointments
• Children and teenager support
• Life, parent, career coaching
• Financial and legal advice
• Health-on-line – 24hr advice line
• Road Accident and Workman’s Compensation Fund claim assistance

 

*These are non-insurance services offered by Kaelo

*Learn more

extraRewards

Bought as part of the Lifestyle Benefits at R55 | month

 

A rewards programme that gives policy holders access to immediate 20% discount on basket of over 2,500 health, home care, personal care, and baby products from leading brands.

 

Available at Dis-Chem stores and Dis-Chem online.

 

*See more detail

*Learn more