Gap cover that goes beyond the limits of your medical aid

The medical scheme may require an upfront payment for certain scopes and scans performed in-hospital or in a day clinic.

This benefit covers the co-payment or deductible that has been applied by the medical scheme.

For approved cancer treatments, this benefit covers:

• The shortfalls for cancer related treatment when a patient uses a provider that falls outside of the scheme’s network of providers
• The co-payments imposed for specific cancer related treatment
• The co-payments imposed once the oncology benefit limit has been reached

Amounts paid under this benefit will be subject to the overall annual limit per life insured.

If using a hospital outside of the prescribed network, the scheme will charge a co-payment. The benefit covers the co-payment that has been applied by the medical scheme.

This benefit covers:

• Unlimited hospital stays within the NetcarePlus network
• One hospital stay per annum up to R10 000 outside the NetcarePlus network

Amounts paid under this benefit will be subject to the overall annual limit per life insured.

Your medical scheme may apply a sub-limit on certain in-hospital medical procedures, prosthetic devices, length of stay in a mental health institution, rehabilitation, step-down or sub-acute facility. We will cover the shortfall once you have reached the sub-limit up to a maximum of R35 000 for each person per annum.

This benefit covers:

• Additional cost, incurred by the insured once the sub-limit has been reached for a procedure or prosthesis.
• The cost of an additional 5 days in a mental health institution, rehabilitation, step down or sub-acute facility.

This benefit will be subject to a maximum of R35 000 per insured per annum. Amounts paid under this benefit will be subject to the overall annual limit per life insured.

This benefit covers:

• Covers the shortfall between the amount charged by the treating doctor and the amount paid by the medical aid. The difference that will be covered will be limited to 300% or 500% of your medical scheme tariff.
• Covers the shortfall due to sub-limits applied by the scheme or co-payments for any tests, scans or appliances that are deemed medically necessary by the treating doctor in diagnosing or treating the patient
• Covers the costs incurred in an Emergency Department, if your savings account has run out or if you have depleted your day-to-day benefit sub-limit, when treating a patient for an emergency medical condition

This benefit covers the following costs due to a trauma event:

• The difference between the amount charged by a registered counsellor or psychologist, for counselling sessions, and amount covered by your medical scheme. Your medical scheme must pay the first portion of your claim.
• The cost of counselling sessions with a registered counsellor or psychologist once you have run out of your medical scheme savings or if you have reached your benefit sub-limit.

A trauma event is when you are:

• A victim or a witness of a violent crime
• Involved in an accident
• Diagnosed with a life-threatening illness or has a loved one diagnosed with a life-threatening illness
• Mourning the death of a loved one

The benefit is subject to a maximum of R10 000 per insured per annum. Amounts paid under this benefit will be subject to the overall annual limit per life insured.

In the unfortunate event that you pass away or become totally and permanently disabled due to an accident, we will pay your NetcarePlus GapCare premiums and your medical scheme contributions for 6 months up to a maximum of R5 000 a month. This amount does not accumulate to the overall limit.

This benefit covers:

When your medical scheme has paid a portion of your out-of-hospital medical specialist claim, we will cover the shortfalls for:

• Out-of-hospital consultations.
• Medical treatment, provided out-of-hospital.

Amounts paid under this benefit will be subject to the overall annual limit per life insured.

Once you have run out of your medical scheme savings or if you have reached your day-to-day benefit sub-limit, we extend your cover for:

• Medical specialist consultation costs that are deemed necessary by a General Practitioner.
• Basic dentistry

• Specialised Dentistry

• Specialised radiology or pathology that is deemed necessary by a patient’s general practitioner or specialist for treatment and diagnosis purposes

This benefit will be subject to a maximum of R20,000 per insured per annum. Amounts paid under this benefit will be subject to the overall annual limit per life insured.

The benefit is not applicable if you belong to a Hospital Plan only.