Gap cover starts paying where your medical aid stops paying
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Why Gap Cover
One of the most frequently asked questions is: “Why did my medical aid not cover the full cost of my hospitalisation?”
In South Africa, medical schemes have different options from which you can choose, with varying benefits. When choosing a medical aid option, you will see that professional services (such as the surgeon or anesthetist) in hospital will be reimbursed at either 100% or 200% of the scheme rate.
Now anyone will be forgiven for assuming that being covered at 100% means that you are fully covered… However, specialists in South Africa are not regulated as to what they can charge patients for their services, and could charge in excess of the 100% rate which medical schemes are willing to pay – sometimes as much as 900% of the scheme rate!
The end result – the patient ends up with a shortfall on the specialist’s account, which he has to pay out of his pocket.
We offer the ULTIMATE GAP COVER product, which is underwritten by Sirago.
Examples of Sirago Claims
Paid in 2023
Confinement Claim
Delivery by Caesarean Section
Gynaecologist Charged:
R29 500.00
Medical Scheme Paid:
R4 177.70
Sirago Paid:
R25 322.30
Member Paid:
R0.00
Heart Disease Claim
Angiogram
Anaesthesist Charged:
R20 531.70
Medical Scheme Paid:
R5 789.48
Sirago Paid:
R14 742.22
Surgeon Charged:
R28 942.10
Medical Scheme Paid:
R9 924.20
Sirago Paid:
R19 017.90
Member Paid:
R0.00
Total Gap Cover Paid:
R33 760.12
Orthopaedic Admission via Emergency Room
Joint Ligament Reconstruction
Orthopaedic Surgeon Charged:
R35 163.55
Medical Scheme Paid:
R11 553.00
Sirago Paid:
R23 610.55
Member Paid:
R0.00
Consultation Claim
Out-of-Hospital Specialist
Dermatologist Charged:
R2 540.00
Medical Scheme Paid:
R1 252.10
Sirago Paid:
R1 287.90
Member Paid:
R0.00
Cancer Claim
Breast Reconstructive Surgery (Affected Breast)
Plastic Surgeon Charged:
R33 908.95
Medical Scheme Paid:
R13 248.20
Sirago Paid:
R20 660.75
Member Paid:
R0.00
Choosing the Ideal Gap Cover Policy
We have negotiated the best possible terms, which means that we can offer you:
- No general 3-month waiting period
- No maximum entry age
- Benefit paid straight into your bank account
- Premiums that are lower than the open market
We cover policyholders and beneficiaries of all ages. The benchmark for premium determination is based on whether you join as an individual, or as a family, and the prospective policyholder’s age at the inception of the policy according to the following two age bands:
- 0 to 64 years
- 65 years or older
Gap cover offers many benefits including cover for co-payments on scopes and scans and cancer-related benefits, such as cover for co-payments above the medical scheme’s threshold.
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