Here is a typical acceptance letter for gap cover:
Thank you for taking out the Medical Gap Cover policy.
Attached please find the policy wording which sets out the terms and conditions. Please read your policy document carefully for information on waiting periods, policy limits and exclusions.
Please remember that this policy is an insurance policy and not a medical scheme and it is a condition of continued cover that you remain a member or dependent of a registered South African Medical Scheme at all times during the term of this policy.
The gap benefit has no annual limit and it covers the difference between the medical practitioner’s charges for treatments received in hospital up to a maximum of 5 times the medical scheme tariff, less the actual amount payable by the medical scheme.
Typical explanation of gap cover benefits
Your Medical GAP policy also provides the following cover typically (please refer to the policy for terms and conditions):
- Shortfalls for treatment cost for certain out-patient procedures as listed in the policy.
- Cancer benefit of R25 000 payable on first diagnosis of cancer as defined in the policy.
- Unlimited cover for co-payments and deductibles including MRI and CAT scans performed in or out of hospital.
- A R20 000 benefit for the reconstruction of the non-affected breast in the event of a single mastectomy due to breast cancer if your medical scheme does not cover the cosmetic reconstruction of the non-affected breast.
- Further cover for the co-payment on cancer treatment when the oncology limit is exceeded subject to a maximum co-payment of 20%.
- Cover of up to R30 000 per year per policy if you have a shortfall due to the scheme limit being exceeded, for an internal prosthesis.
- A Personal Accident Benefit and Accidental Death Benefit of R25 000 as explained in Appendix A.
- Access to Hello Doctor which provides access to GP advice 24/7 via text messages to a team of doctors who will answer all medical and health related questions within 1 hour. You can start using this service within the next 45 days or once you received an e-mail or sms notification about this service. Download the FREE Hello Doctor app from your app store or visit wwww.hellodoctor.com to access our doctors.
Some gap cover exclusions
We draw your attention to the fact that the policy does not cover:
- Hospital account shortfalls for the actual costs of hospitalisation including ward charges and theatre charges (In most cases this should be covered in full by the medical scheme).
- The cost of any materials, equipment or medication.
- Hospital emergency room treatment
- Shortfalls on normal day to day medical practitioner consultations.
- Medical scheme exclusions or benefits not provided/covered by your option plan.
We ask that you check that the details in your policy are correct and advise you to keep this in a safe place, where you or a member of your family can easily find it.
To get a quote for a typical gap cover policy, please complete and submit the form on this page. Please note that only members of South African medical schemes may sign up for gap insurance.