Gap Cover Q&A’s
Are you a member of a medical aid scheme? Good, because medical aid & Gap Cover go together.
To help you make an informed decision, we have listed some common frequently asked questions and answers below.
General Gap Cover
Frequently Asked Questions & Answers
Do I need Medical Aid, or will Gap Cover pay for all my medical bills?
You have to be a member of a Medical Aid Scheme in order to take out Gap Cover. Gap Cover is an add-on product that covers the unforeseen in-hospital expenses not covered by your Medical Aid. Do you need medical aid?
How do I claim from Gap Cover?
The way you claim depends on your Gap Cover product. Some companies such as Discovery calculate your gap claim automatically when you submit your medical aid claim to them.
Where the claim process is manual, Informed Healthcare handles your gap cover claims on your behalf. Simply contact us prior to a planned operation, and we will handle all the paperwork for you.
In the case of an emergency, simply get in touch with us to find out what out-of-pocket expenses will be covered by your Gap Cover policy.
Is there a waiting period after I take out my Gap Cover policy?
When you take out a new Gap Cover policy, you will usually be required to adhere to 4 broad waiting period categories:
- General: There is a general waiting period of 3 months on all benefits, except for claims relating to accidental injury.
- Pre-existing: There is a 12-month pre-existing condition waiting period for which you received advice, treatment, or diagnosis 12 months prior to taking out your Gap Cover policy.
- Specific procedures: Most Gap Cover Providers do not cover a list of specified procedures for the first 10 to 12 months. This list will normally include: spinal, joint replacement, scans & scopes, cardiovascular, cataract and hernia procedures. Exceptions to this rule can be claimed for if injury occurred due to an accident.
- Cancer: There is normally a waiting period for per-diagnosed cancers. Cancers diagnosed prior to taking out your Gap Cover policy have to be in remission for 12 months to 5 years before benefits are claimable.
Ambledown Gap Cover
Frequently Asked Questions & Answers
How often do my Ambledown Gap Cover premiums increase?
Ambledown premium increases occur once a year, taking effect on the 1st of January of every year your policy is active. These premium adjustments will be based on various factors, including:
- Medical inflation,
- Provider disposition (medical practitioner charges increase forecast),
- Various Medical Scheme factors that impact our product benefits.
You will be informed of any adjusts to your premiums with 31 days prior written notice.
Will the Ambledown cover me if I have a Hospital Cash Plan instead of a Medical Aid Hospital Plan?
A: Unfortunately not, Ambledown Gap Cover is only available to members of a registered Medical Aid Scheme.
How long do Ambledown take to process my claims?
A: Most claims will be settled with in 2 weeks of Ambledown receiving all the required documentation.
Discovery Gap Cover
Frequently Asked Questions & Answers
Who is eligible for Discovery Gap Cover?
With exception of members on KeyCare plans, all members of Discovery Health Medical Aid qualify to take out Discovery Gap Cover & Supplementary Illness Benefit.
In order to quality for the Discovery Supplementary Illness Benefit, the main member and spouse must be younger than 60 years old when making an application. This Supplementary Illness Benefit cover ends when you turn 65 years old.
Are Discovery Gap Cover premiums affordable?
Discovery Gap Cover premiums start from as little as R109 a month, this depends on:
- The Gap Cover options you choose,
- Your current Discovery medical aid plan,
- The number of members your plan covers,
- Your age when applying.
Discovery Supplementary Illness Benefit premiums start from as little as R80 a month, this depends on:
- Are you a smoker?
- The number of members on your medical aid plan.
- Your age when you apply.
How to submit Gap Cover claims to Discovery?
Discovery Gap Cover offers a simple & automated claims process. You do not need to submit a separate Gap Cover claim to Discovery, on application the following will be requested from you:
- Consent to access your medical aid claims information.
Discovery will then automatically identify any gap cover claims, and you will be paid out according to your Gap Cover benefits.
You will be supplied with a claim’s statement pointing out where your policy has covered any shortfall expenses.
Gapwise Gap Cover
Frequently Asked Questions & Answers
How do I submit a Gapwise Gap Cover claim?
To submit a claim to Gapwise please download the claim form below, complete the form and email it to claims @sirago.co.za. Please contact us if you have any questions.
What are the Cancer Benefits for the Gapwise plans?
Gapwise Comprehensive
- First Diagnosis Cover – R 10,000.
- Oncology Shortfall Cover – R 164,000 per year,
Sub-Limit On Oncology Co-Pay – R 60,000. - Top-Up – R 50,000 per year where medical aid limits reached.
- Reconstructive Surgery – 200% Gap cover per affected breast, up to R 15,000 for reconstruction of unaffected breast.
Gapwise Ultra
- First Diagnosis Cover – R 20,000.
- Oncology Shortfall Cover – R 164,000 per year,
Sub-Limit On Oncology Co-Pay – R 100,000. - Top-Up – R 100,000 per year where medical aid limits reached.
- Reconstructive Surgery – 300% Gap cover per affected breast, up to R 25,000 for reconstruction of unaffected breast.
T&C’s Apply
What are the Added Benefits per Gapwise plan?
Gapwise Comprehensive
- Accidental Death Cover:
• Principal Member – R 7,500,
• R 5,000 per adult dependant,
• R 3,000 per child dependant. - 12 Month Premium Waiver:
• The premium payer is retrenched,
• Becomes permanently disabled,
• Passes away. - 6 Month Medical Aid Contribution Cover:
R3,000 per month if the premium payer becomes permanently disabled or passes away.
Gapwise Ultra
- Accidental Death Cover:
• Principal Member – R 15,500,
• R 10,000 per adult dependant,
• R 5,000 per child dependant. - 12 Month Premium Waiver:
• The premium payer is retrenched,
• Becomes permanently disabled,
• Passes away. - 6 Month Medical Aid Contribution Cover:
R5,000 per month if the premium payer becomes permanently disabled or passes away.
T&C’s Apply
Sirago Gap Cover
Frequently Asked Questions & Answers
Who is covered by Sirago Gap Cover?
Sirago covers all medical aid policyholders & their beneficiaries of all ages.
Sirago’s premiums are determined based on:
- Whether you join as an individual,
- Or as a family.
A second determining factor is the prospective applicant’s age according to the following three age groups:
- 54 Years or younger,
- Between 55 years to 64 years,
- 65 Years or older.
What steps to I need to take when claiming from Sirago Gap Cover?
Firstly, it is vitally important that you contact Informed Healthcare as soon as possible to determine if the in-hospital service or procedure will be covered by your Gap Cover policy.
When you need to submit a claim to Sirago, all you need to do is get in contact with Informed Healthcare Solutions. We will talk you through the process and supply you with the required documentation to fill out. You will need to scan & email certain documents through to us.
Depending on your claim, the following documentation will be required in order to submit a claim:
- Sirago Gap Cover claim form,
- Doctor’s account or service provider’s invoice,
- Hospital bill or specialist’s invoice,
- Emergency or casualty ward account,
- Medical aid claim statement.
What happens if I have an emergency?
Depending on your Gap Cover policy, Sirago offers Out-of-Hospital Benefits. This out-of-hospital benefit covers emergency medical treatment due to a trauma, accident, or illness at any registered emergency facility near you.
Stratum Gap Cover
Frequently Asked Questions & Answers
Does Stratum have a Overall Policy Limit (OPL)?
There is a policy limit of R 173 000 that is applied across all benefits offered by your Stratum Benefits policy. If the policy limit has been reached before the yearly renewal, you will not be able to claim from your policy for the remainder of that year. The OPL renews on the 1st of January every year the policy is active.
Are my Stratum Gap Cover premiums tax deductible?
Unfortunately not, Gap Cover is Short-Term Insurance, due to this your Gap Cover premiums are not tax-deductible.
Am I covered for Co-payments and Sub-limits?
That depends on the policy you take out with Stratum. If your policy states that there is Co-payment Cover, Stratum will refund any amount or percentage of in or out-of-hospital co-payments and deductibles.
As stated above, if your policy includes Sub-limit Cover, any annual limits placed on procedures by your Medical Aid should be covered by your Stratum policy.
For example, your Medical Aid limit is R 45 000 for a cardiac pacemaker, which costs R 60 000, you are left with an out-of-pocket expense of R15 000. The sub-limit difference of R 15 000 is typically what Stratum would cover.
