Gap Cover – Austen Morris Associates Health Care

GAP cover series

Covers you and your immediate family for procedures incurred whilst hospitalised, where the medical practitioner’s rates exceed that of your medical aid reimbursement rates, refunding you the shortfall (GAP).

Example shortfalls:

Procedure	Cost	Medical Aid Payout	Shortfall	Gap Claim
Appendectomy	R3,441.46	R1,388.20	R2,053.26	R2,053.26
	R12,605.8			R8,4133.7
Caesarean Section	6	R4,192.10	R8,413.76	6
	R40,751.8		R27,164.2	R27,164.2
Coronary Bypass	0	R13,587.60	0	0
	R12,977.8
Hysterectomy	0	R4,751.00	R8,226.80	R8,226.80
	R12,297.7
Tonsillectomy	0	R4,119.91	R8,177.79	R8,177.79
Wisdom Teeth Removal	R6,260.00	R1,958.50	R4,301.50	R4,301.50

Gap 100

For any account received from a Medical Practitioner from date of admission to hospital to discharge date, the insured will receive a benefit equal to the actual cost incurred limited to 5 times the Medical Scheme Tariff less the Medical Scheme Tariff for treatment received whilst admitted to hospital.

The cost of a medical or a surgical procedure following an Emergency incurred in a hospital casualty unit of a Hospital where such costs were not met by the Medical scheme.

Gap 200

For any account received from a Medical Practitioner from date of admission to hospital to discharge date, the insured will receive a benefit equal to the actual cost incurred limited to 3 times the Medical Scheme Tariff less the Medical Scheme Tariff for treatment received whilst admitted to hospital.

The cost of a medical or a surgical procedure following an Emergency incurred in a hospital casualty unit of a Hospital where such costs were not met by the Medical scheme.

Co-Payment

Upfront co‐payments required by medical schemes from their members for hospital admissions, scans and certain surgical procedures are covered. This cover is provided without an annual maximum claim limit.

Our policy covers the shortfall, either the co‐payment after the sub‐limitation or the sub‐limitation for cancer treatment for traditional methods or for either the co‐payment or sub‐limitation for treatment of cancer with biological drugs.

Sub Limitation Cover

Does your medical aid limit the amount of cover you enjoy for a specific in‐hospital procedure? If so, the Sub‐Limitation Cover policy will: Extend in‐hospital medical scheme sub‐limits. Our policy covers the shortfall, either the co‐payment after the sub‐limitation or the sub‐limitation for cancer treatment for traditional methods or for either the co‐payment or sub‐limitation for treatment of cancer with biological drugs.

Cancer Cover

Often exceed your medical aid limit cover for the treatment of cancer? If so, the Cancer Cover policy will enhance your current level of medical aid cover for the traditional treatment of cancer; while enhance your current level of medical aid cover for the treatment of cancer using Biological drugs as defined.

There is a total exclusion on Cancer Cover for any insured who has been diagnosed with cancer prior to date of entry.

Our policy covers the shortfall, either the co-payment after the sub-limitation or the sub-limitation for cancer treatment for traditional methods or for either the co-payment or sub-limitation for treatment of cancer with biological drugs.

Casualty Benefit

Cost of medical or surgical procedures incurred in a hospital casualty unit, following an emergency, where such costs were not met by the Medical scheme.

The cost of a medical or a surgical procedure following an emergency incurred in a hospital casualty unit of a hospital where such costs were not met by the medical scheme.

Premium Waiver

6 months’ medical aid premium waiver for insured dependents on the principal’s medical aid in the event of the death or permanent and total disability of the principal insured.

Provides a lump sum payment equal to 6 months member’s medical scheme contribution.