About Ambledown Medical Shortfall Cover

December 10, 2021

People are often shocked when medical aids fail to pay all hospitalisation costs – Ambledown Medical Shortfall Cover can help you bridge the gap.

Medical schemes have set tariff ceilings and pay out accordingly. When medical practitioners impose higher fees it is the members who suffer. These unexpected out-of-pocket expenses can be crippling.

What Gap Cover Can Do

That’s when gap cover comes in – Ambledown pays the shortfall between the medical aid rates and what you have to pay. It covers the principal member as well as their dependents.

For more information on gap cover and your medical aid, click here.

What Ambledown Medical Shortfall Cover Offers

Coverage is offered for the following:

  • Hospital procedures
  • Out-patient chemotherapy or radiotherapy
  • For out-patient dialysis.


Limits to the Cover

  • In fact, Ambledown’s Gap Series offers a generous annual limit of R2 million.
  • The insurance will pay up to five times more than the MST limits.
  • The cover excludes hospital fees.
  • It excludes additional costs for prosthesis, medication, and materials.
  • It includes services given by medical professionals, during in-hospital procedures. This includes physiotherapists.
  • The limit per family annually for co-payments that related to MRI and CT Scans is R100 000. (Co-payments come into play if  the medical practitioner wants upfront payment.)
  • Sub-limitation cover is limited  per family annually.
  • Members must obtain authorization beforehand and they must use a recognised network hospital.


Cancer Patients

If diagnosed with cancer you can expect the following:

  • Insured Cancer patients receive a set amount per treatment cycle.
  • The insurance covers co-payments and deductibles.
  • Sub-limitations that the medical schemes impose are included.
  • It also covers some cancers and also includes in-hospital expenses and medication.
  • Cover includes out-patient treatments but it does exclude consultations with specialists.


The Casualty Benefit of  Ambledown Medical Shortfall Cover

The casualty benefit covers *emergency medical treatment in a hospital casualty unit.

Admission to casualty is covered if not settled by medical aid with limits.

(*Emergency is defined as a case where medical intervention is essential.)

Premium Waiver Benefit: In the event of death or permanent disability of a principal member, Ambledown will pay his/her medical scheme premiums for six months.

GAP Listed Procedure Enhancer covers the following:

  • Reconstructive dentistry is included if caused by trauma and functional nasal surgery
  • Oesophageal reflux and hiatus hernia surgeries
  • Treatments or surgeries for back and neck conditions
  • Joint replacements, including but not limited to hips, shoulders, knees and elbows
  • Procedures, devices and processors for cochlear and auditory brain implants
  • Internal nerve stimulators
  • Bunionectomy
  • Arthroscopy
  • Varicose vein removals and skin disorders such as benign growth and lipomas

This GAP 100 benefit will pay out a maximum of five times the Medical Scheme Tariff. An annual limit applies.

All info was correct at time of publishing