WHY DO YOU NEED GAP COVER?

The Council for Medical Schemes recommends an annual medical aid rate – this is the base rate that can be charged by all medical practitioners for medical procedures. Most medical aids agree to pay up to a certain percentage of this rate – in most cases up to 300% of this rate. However, medical practitioners are free to charge whatever they want for their services, and should your provider charge more, it will be your responsibility to cover the shortfall.

For example: Let’s say your medical aid covers up to 300% of the medical aid rate. If a medical practitioner charges 500% of medical aid rates, your medical aid will cover the first 300% and you will have to pay the additional 200%. Medical practitioners may also request certain tests and procedures which would also require co-payments from your pocket.

Medical procedures are expensive, and this can mean an instant bill of tens of thousands of Rands, if not more. Gap Cover is important, additional insurance you buy in conjunction with your medical aid to cover this shortfall.

Old Mutual Gap Cover is not a medical scheme and the cover is not the same as that of a medical scheme. This policy is not a substitute for medical scheme membership.


HEALTHY BENEFITS TO PROTECT YOU AGAINST SHORTFALLS

Old Mutual Gap Cover offers excellent In-Hospital, In- and Out-of-Hospital Oncology and Out-of-Hospital benefits to cover defined medical expense shortfalls for tariffs, oncology, sub-limits, co-payments and deductibles, plus a Benefit Extender in addition to the core benefits.

Old Mutual Gap Cover:
  • Available to members of a registered medical scheme.
  • Pays up to five times (500%) the medical scheme tariff fee if designated service providers are used.
  • Pays up to one times (100%) the medical scheme tariff fee for shortfalls on:
    - maxillofacial and back and spinal surgery OR for shortfalls where a non-designated service provider was used on a group network option and.
  • Cover applies to the member, spouse and children (up to 26 years of age).
  • Members on multiple medical schemes can be covered under a single Old Mutual Gap Cover policy.
  • A spouse, who is a dependant on their partner’s medical scheme, can take up an Old Mutual Gap Cover policy and the family will be covered.
Covered events
  • Hospitalisation for accidental harm, illness or other health incidents.
  • Oncology treatment, including chemotherapy, radiotherapy or other drug regimen.
  • Kidney dialysis for the treatment of acute or chronic renal failure.
  • Accidental harm resulting in emergency medical treatment at the out-patient casualty or trauma ward of a hospital.

GAP COVER BENEFITS:

IN-HOSPITAL BENEFITS

In-Hospital benefits include cover for substantial tariff shortfalls, co-payments or sub-limits, co-payment and deductibles and shortfalls from sub-limits arising from defined in-hospital consultations and procedures.

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IN- AND OUT-OF-HOSPITAL ONCOLOGY BENEFITS

In- and Out-of-Hospital Oncology benefits include cover for shortfalls on oncology treatment. These shortfalls can be significant and can occur as oncology tariff shortfalls, co-payments or sub-limits.

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OUT-OF-HOSPITAL BENEFITS

Out-of-Hospital Benefits provide cover for tariff shortfalls on surgical procedures, treatments and medical expense shortfalls received as an out-patient, as well as cover for accidental casualty.

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BENEFIT EXTENDER

The Benefit Extender was designed to assist with additional benefits (over and above the core benefits) for certain medical events, resulting in additional non-medical expenses that will not be covered by your medical scheme. These benefits can be used at own discretion.

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MAXIMUM COMPENSATION FOR ALL GAP COVER BENEFITS*

The total maximum Compensation Limit payable for all Core Benefits and Benefit Extender will be limited to R174 000 (one hundred and seventy-four thousand rand) per family member, per annum.

  • Includes cover for Policyholder and six dependants.

* Cover benefits, limits and maximum compensation limit applicable from 1 January 2022.

Terms & Conditions apply.


IMPORTANT TO NOTE:

  • During the first 12 months of membership, a pre-existing condition waiting period applies.
  • During the first 3 months of membership, a general waiting period applies.
  • During the first 12 months of membership, a pregnancy waiting period applies.

Please note the 3 months general waiting period, 12 months pre-existing condition waiting period and 12 months pregnancy waiting period apply to an insured person from the time that such person's cover commences under the policy (to run concurrently if two or more waiting periods are applicable to an insured family member).




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