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  1. What is the annual limit on my policy? / Is there an annual limit on my policy?

    The total benefit per policy is limited to R157 000 per beneficiary per annum.

  2. What is GapCover®?

    GapCover® provides cover for the difference in the amount charged by a Registered Medical Professional and the Medical Scheme Tariff for services rendered while admitted in hospital. The maximum amount that will be paid towards this shortfall is calculated at 5 times (or 500% of) the medical scheme tariff defined by your medical scheme; less the amount payable or actually paid by your medical scheme or 1 times the medical scheme tariff, whichever is the higher, limited to R157 000 per beneficiary, per annum.

  3. Why do I need gap cover?

    There is often a shortfall between what a medical scheme pays and the actual cost of a procedure or treatment, because service providers are entitled to charge more than the medical scheme rate. The shortfall then becomes the member's responsibility and he/she will therefore need to have additional cover under these circumstances. 

    Some Hospital and Comprehensive Medical Plans offer cover at 100%, 150% or 200% of medical scheme rates for hospitalisation only, while the actual costs could be more than 500% of medical scheme rates. GapCover® will cover the difference between what your medical scheme will pay and the actual cost of in-hospital doctor's bills, up to a maximum of 500% of medical scheme rates. 

    Listed below are four common medical procedures, with the combined charges of the specialist and anaesthetist opposite each. The third column illustrates the payment shortfall an individual on a standard, 100% of MSR (medical scheme rate), scheme option would experience. 

    Procedure Amount charged by service provider Potential shortfall incurred (payable by GapCover®)
    Colonoscopy R14 509.82 R4 805.42
    Back Fusion R105 301.95 R68 188.31
    Tonsillectomy R19 081.86 R11 958.34
    Joint Replacement R46 660.48 R23 597.41

    These are just a few examples of the many different treatments and operations covered by GapCover®.

    *The GapCover® benefit is calculated as 5 times (or 500% of) the medical scheme tariff defined by your medical scheme; less the amount payable or actually paid by your medical scheme or 1 times the medical scheme tariff, whichever is the higher.

  4. Can I use GapCover® in conjunction with any medical scheme?

    Yes, this specific gap cover policy can be used in conjunction with any medical scheme registered in South Africa.

  5. What is Co-Pay Cover? 

    CoPay Cover benefit provides cover for procedural co-payments and hospital admission fees (the excesses imposed in terms of your medical scheme rules) for procedures performed as an in-patient or and out-patient, including Specialised Radiology such as MRI and CT Scans, subject to the overall annual limit and limited to R12 800 per event. The benefit also includes additional cover up to R12 800 for the co-payment charged when using a non-DSP Hospital, limited to one event per calendar year, per policy. 

    Examples of listed Co-payments

    Scheme Name Procedure Listed Co-Payment
    Scheme A Gastroscopy in hospital R4 250
    Scheme B Gastroscopy in hospital R4 500
    Scheme A MRI/CT scans out of hospital R3 350
    Scheme B MRI/CT scans in and out of hospital R2 500
    Scheme B Hospital admission fee R1 500
    Scheme A Dental Procedures in hospital R6 200
    Scheme B Dental Procedures in hospital R1 500
  6. Does my GapCover® Policy automatically cover co-payments?

    No, a GapCover® policy does not cover co-payments, but Co-Pay cover benefit is available as an additional benefit on the Combined Cover option. (refer to GapCover Application Form). 

  7. What is the difference between GapCover® and CoPay cover benefits?

    GapCover® benefit will cover the difference between what your medical scheme will pay and the actual cost of in-hospital doctor's bills, up to a maximum of 500% of medical scheme rates.

    CoPay Cover benefit will cover procedural co-payments (the specified amounts are indicated in your Medical Scheme Rules) for procedures while you are an in-patient or an out-patient, including Specialised Radiology such a MRI and CT Scans.

  8. What does the term “Combined cover” mean?

    It is when you have chosen the GapCover® and CoPay Cover benefit together (Combined).

  9. Which companies are involved in GapCover®?

    GapCover® is a product underwritten by Western National Insurance Company Limited Reg. No. 2005/17379/06 and administered by Insuremed Administrators (Pty) Limited Reg. No. 2012/019149/07.

  10. What is the medical scheme agreed rate?

    The Council of Medical Schemes has specific codes for procedures and each code has a specific rate which is used as a guideline by medical schemes. 

  11. Are day-to-day services covered under the GapCover® policy?

    No, normal visits to your GP or specialist, and auxiliary services on a day-to-day basis are not part of your GapCover® policy benefits, unless otherwise specified in the policy wording.

  12. Does this policy cover Prescribed Minimum Benefits (PMB)?

    This GapCover® policy does not include benefits for PMB claims.

  13. What is a PMB?

    Prescribed Minimum Benefits (PMB) are a set of defined benefits to ensure all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable.

    PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of:

  14. What are the policy exclusions?

    Please contact your consultant for a list of the standard policy exclusions.

  15. What do GapCover® and Combined Cover cost?

    Please refer to the option premiums as indicated on the application form.

  16. Are premium increases applicable to the GapCover® and Combined Cover policies?

    Yes, a premium increase may be applied on an annual basis.

  17. Are there any additional costs?

    No, intermediary and administration costs are included in your monthly premium.

  18. When will the first premium payments be debited?

    The first premium will be debited within the first month of cover - see the Application form for debit order dates available.

  19. Will the GapCover® premium be debited together with the medical scheme contribution?

    No, GapCover® is a separate insurance product administrated by a different company.

  20. What happens if the debit order date falls on a weekend or public holiday?

    A debit order will be deducted on the next working day.

  21. Who can apply for GapCover® and Combined Cover?

    GapCover® and Combined Cover are both available to individuals who are members of a registered South African medical scheme.

  22. Do I have to go for a medical examination to qualify for either GapCover® or CoPay Cover?

    No medical examination is required.

  23. Who is covered by this policy?

    Cover is provided for you, your spouse or life partner and all children registered as child dependents on your medical scheme as well as your GapCover® policy. Children are covered up to the age of 26, unless in the case of permanent physical or mental disability. Dependents that are not registered on your policy will not enjoy cover.

  24. Is a newborn baby covered under the GapCover® policy?

    New-born babies are covered from birth with no waiting periods, provided the baby is registered on the policy within 30 days from date of birth. Should the baby be registered more than 30 days after the birth, waiting periods will apply.

  25. Is a new spouse covered under the GapCover® policy?

    Yes, your new spouse or life partner will be covered on the policy. Normal underwriting will apply. Please note that dependent registration is required and will not be backdated. 

  26. Can I add more than one spouse to the GapCover® policy?

    No, GapCover® allows for only one spouse, or life partner, to be registered as a dependent.

  27. When will I receive my policy documents?

    Your policy documents will be e-mailed to you within one week of registration of your application, provided that the application form is completed in full and no additional information is required. Documents can be posted on request.

  28. When will I start enjoying the cover under the policy, i.e. when will the GapCover® policy come into operation?

    Cover will commence on the 1st day of the month when your first premium is received. Terms and conditions apply.

  29. When can I submit a GapCover® or Combined Cover claim?

    It is advisable to submit the GapCover® claim as soon as your medical scheme has paid their portion of the account, but not later than four months of receipt of the medical scheme payment.

  30. What documents are required for the submission of a GapCover® claim?

    A completed claim form, available on request or by CLICKING HERE, must be accompanied by:
    • Detailed copies of all relevant doctors’ accounts
    • A clear copy of the hospital account
    • A detailed Medical Scheme claims statement reflecting the shortfall to the doctor
    • A copy of your medical scheme authorisation confirmation
    • A copy of the Medical Scheme membership certificate

  31. To whom will the GapCover® claim benefit be paid out?

    All claim payments are made directly to the debit order account details. For security purposes, should the bank details for payment of claims differ from the debit order account details listed on the policy, proof of banking details must be provided with your claim.

  32. Should any of my details or those of my dependents change, should it be communicated and what process do I need to follow to change these details on my GapCover® policy?

    Yes, any changes must be communicated to GapCover via email (admin@insuremed.co.za) within 30 days of the change. (Please attach a copy of your updated medical scheme membership certificate as confirmation of changes in respect of your dependents.) Kindly contact the Administrator for assistance with any other changes.

  33. Will new waiting periods be imposed on my GapCover® policy when I change from one medical scheme to another?

    No. Although the GapCover® policy runs in conjunction with a medical scheme, the GapCover® waiting periods will not be affected when changing medical schemes.

  34. When does the GapCover® policy end?

    The policy will be terminated when the policyholder cancels the policy in writing, or when the policyholder allows the policy to lapse.

  35. What process must I follow to cancel the policy?

    To cancel the policy, the administrators must be given one calendar month’s notice, in writing, in order to cancel the policy. (A cancellation form is available on request.)

  36. When will a GapCover® policy be cancelled automatically?

    It will be cancelled automatically once three consecutive premiums have not been received, as the policy will then be three months in arrears.

  37. Can a GapCover® policy be reinstated?

    Yes, within three months from date of cancellation the policy can be reactivated. If the policy is cancelled for a period longer than 3 months, a new application form must be completed.

  38. What is classified as an incident or event?

    A typical example of an incident or event might be as follows:

    As the member of a medical scheme you suffer from persistent migraines; your medical practitioner requests an MRI (co payment of R2 500 applies); the MRI indicates bleeding on the brain and you are admitted to hospital for treatment (hospital admission fee of R1 500 applies); while receiving treatment a second MRI is done (co-payment of R2 500 applies) which confirms that you need an operation.

    The co-payments for both MRI scans and the admission fee will be seen as one event.

  39. Can I claim for co-payments on GP visits and medication?

    CoPay Cover provides cover for specified co-payments on procedures and scans performed in- or out-of-hospital. Co-payments on medication and doctors consultations are not covered.

  40. What underwriting will be applied to new policies?

    A three month general waiting period shall apply in respect of all claims received in this period, unless the claim is as a result of an accident. 
    A 12-month pre-existing condition waiting period shall apply in respect of all pre-existing conditions. 
    Any previous cover with similar benefits will be taken into consideration when calculating your waiting periods.