The importance of gap cover

You may think your medical scheme provides full cover. Sadly, this wont always be the case.

I have medical scheme cover.
Why do I need gap too?

Healthcare is expensive and all medical schemes are forced to impose limitations on the cover they provide. These shortfalls can place a huge toll – not only on your finances, but more importantly, the treatment outcomes of your loved ones.

Our gap plans start from R365 per month ranging in cover to meet your budget and tailored to meet your family’s specific requirements. Get a detailed quote in just 2 minutes or review the below information to understand the gaps and make an informed choice about which plan will best meet your most critical priorities.

To help you select a gap plan that meets your most critical priorities and budget, the information below outlines where typical shortfalls in your medical scheme may occur:

Medical scheme tariffs

When hospitalized, specialist medical practitioners are essential to the diagnosis and successful treatment. Your medical scheme will only cover practitioner fees at the stipulated medical scheme tariff.
A private specialist may charge up to 6x more than the tariff allowance. You are liable for the balance.

Gap pays the difference up to 600%.

There may be times when the majority of your bill is not covered by your medical scheme. Gap pays the difference up to 600%.

What is a PMB?

Prescribed Minimum Benefit (PMB) refers to a set of essential healthcare services and treatments that must be provided by medical schemes (health insurance providers) to their members, regardless of the specific plan they have. The purpose of Prescribed Minimum Benefits is to ensure that all members have access to a basic level of healthcare services, regardless of their financial means.

Innovative procedures & treatments your doctors may recommend, may be excluded from your medical cover.

Non-PMB Treatments

Your medical scheme is not required to provide cover for treatment options that do not appear on what is called the Prescribed Minimum Benefits (PMB) list. This means you may not be eligible to receive the treatments your medical specialist may recommend – such as biological drugs for the treatment of cancer.

Including a cancer cover benefit on your gap plan, provides you with access to continued innovative cancer treatments, to assist you when your medical scheme limits have been reached.

What is PMB treatment?
Prescribed Minimum Benefit (PMB) refers to a set of essential healthcare services and treatments that must be provided by medical schemes (health insurance providers) to their members, regardless of the specific plan they have. The purpose of Prescribed Minimum Benefits is to ensure that all members have access to a basic level of healthcare services, regardless of their financial means.

It may surprise you to discover that casualty ward expenses are excluded from hospital plan cover.

Casualty ward expenses

Hospital plans don’t cover visits to the emergency or casualty rooms as these are considered ‘out-of-hospital’. Unless the scheme offers a specific emergency benefit, the visit to the ER would be paid from your medical savings. Thus, if your medical savings are depleted, you would be paying for casualty ward expenses from your pocket.

Including a casualty cover benefit on your gap plan allows for
R12 000 per person per annum for emergency treatment in the casualty ward of a hospital in the event of accidental injury. Cover is also extended for emergency after-hours treatment required for illness, at a registered medical facility, for children younger than 5 years of age.

If you hit a sub-limit, you may have to forgo further treatment unless you can cover the costs yourself.

Sub-limits

This refers to the maximum amount that your medical scheme makes available from your plan for certain types of procedures or treatments. If you reach this limit, you may face the prospect of having to forgo further treatment. That’s not a situation anyone would want to find themselves in when fighting a life-threatening illness.

Including a sub-limit cover benefit on your gap plan boosts the total levels of cover.

Co-payments

You may need an MRI or CT Scan to diagnose a potential health threat. Think it’s 100% covered? It’s not. Your medical scheme will request a co-payment from you (a fixed amount you are required to pay before certain procedures like MRI or CT scans). Please be sure to check what co-payments are imposed by your medical scheme.

Including a procedural co-payment benefit on your gap plan, to cover the co-payment up to R198 000 per person per annum.

You may not be free to choose the private hospital facility you wish to visit.

Non-designated service providers penalty

Got a dire emergency and find yourself at your nearest hospital?
Your medical scheme may demand a co-payment from you if the hospital falls outside of its network of preferred service providers.

Including a co-payment benefit on your gap plan, covers penalties up to R15 000 per family per annum.

Our gap cover plans start from
R365 p/m for the whole family

Pick your cover to meet your budget and most critical priorities.

BRIDGE THE GAP – GET YOUR QUOTE NOW

*Prices quoted are indicative of your risk profile as defined by Medway.

When will cover cease on this policy?Trish Lee2023-11-17T09:40:41+02:00

When will cover cease on this policy?

On the death of the principal insured.

When you do not pay your premium for 2 consecutive months.

When will my claim not be processed?Trish Lee2023-11-17T09:40:33+02:00

When will my claim not be processed?

Where your policy is in arrears.

Where you are claiming outside the 12-month period that you have in which to claim and/or the claim was not submitted within 6 months of the incident, and you do not sufficiently justify the lateness of submission.

Where you have not provided all the required documentation.

Where the dependant you are claiming for no longer meets the eligible spouse/dependant definition.

What waiting periods apply to this policy?Trish Lee2023-11-17T09:40:25+02:00

What waiting periods apply to this policy?

6 months waiting period applies to any pre-existing condition/natural death.
A 12-month waiting period applies for suicide
No waiting periods apply to accidental death.

What are the general exclusions of this policy?Trish Lee2023-11-17T09:40:18+02:00

What are the general exclusions of this policy?

While there are no general exclusions that apply to this policy, it’s important to note that a 12-month waiting period is in place for coverage related to suicide.

What are the general conditions of this policy?Trish Lee2023-11-17T09:44:06+02:00

What are the general conditions of this policy?

Cooling-off period of 31 days, from policy inception, is allowed i.e., within this period, you may cancel and get refunded.

Notice to terminate is 31 days.

Premiums are paid monthly in advance.

Any premium received after 40 days of usual strike date, will result in no cover for that month.

No refunds are due in the case of the cancellation of a policy, other than in the cooling-off period.

How long does it take to process my claim?Trish Lee2023-11-17T09:39:57+02:00

How long does it take to process my claim?

A complete funeral claim (this includes a 100% fully completed claim form plus all the required supporting documentation), is processed within 48 working hours.

How do I submit a claim?Trish Lee2023-11-17T09:39:49+02:00

How do I submit a claim?

Contact our Customer Care Centre on 0860 633 929, email customercare@medway.co.za or send us a WhatsApp message.

You will be emailed the appropriate forms along with detailed requirements.

Provided you submit all the correct information, your claim will be processed within the time frames stipulated.

Who may be covered under this policy?Trish Lee2023-11-17T09:39:39+02:00

Who may be covered under this policy?

You, your spouse or life partner and your biological children and legally adopted or fostered children.

Please note there is an age limit of 21 years for cover for children, which may be extended to age 27 where a student is registered at a bona fide tertiary education institution and is still financially dependent on you. The student must be registered as a child dependant on the medical scheme.

Permanently disabled children are not bound by this age restriction.

No grandchildren will be covered unless you are able to prove that they are 100% financially dependent on you and in the absence of their own parents.

How does Bereavement cover work?Trish Lee2023-11-17T09:39:18+02:00

How does Bereavement cover work?

The Bereavement benefit provides comprehensive cover that goes beyond basic funeral expenses, ensuring support for additional funeral-related and ongoing costs during challenging times.

Questions & Answers

Life

How does Bereavement cover work?Trish Lee2023-11-17T09:39:18+02:00

How does Bereavement cover work?

The Bereavement benefit provides comprehensive cover that goes beyond basic funeral expenses, ensuring support for additional funeral-related and ongoing costs during challenging times.

Who may be covered under this policy?Trish Lee2023-11-17T09:39:39+02:00

Who may be covered under this policy?

You, your spouse or life partner and your biological children and legally adopted or fostered children.

Permanently disabled children are not bound by this age restriction.

No grandchildren will be covered unless you are able to prove that they are 100% financially dependent on you and in the absence of their own parents.

How do I submit a claim?Trish Lee2023-11-17T09:39:49+02:00

How do I submit a claim?

Contact our Customer Care Centre on 0860 633 929, email customercare@medway.co.za or send us a WhatsApp message.

You will be emailed the appropriate forms along with detailed requirements.

Provided you submit all the correct information, your claim will be processed within the time frames stipulated.

How long does it take to process my claim?Trish Lee2023-11-17T09:39:57+02:00

How long does it take to process my claim?

A complete funeral claim (this includes a 100% fully completed claim form plus all the required supporting documentation), is processed within 48 working hours.

What are the general conditions of this policy?Trish Lee2023-11-17T09:44:06+02:00

What are the general conditions of this policy?

Cooling-off period of 31 days, from policy inception, is allowed i.e., within this period, you may cancel and get refunded.

Notice to terminate is 31 days.

Premiums are paid monthly in advance.

Any premium received after 40 days of usual strike date, will result in no cover for that month.

No refunds are due in the case of the cancellation of a policy, other than in the cooling-off period.

What are the general exclusions of this policy?Trish Lee2023-11-17T09:40:18+02:00

What are the general exclusions of this policy?

While there are no general exclusions that apply to this policy, it’s important to note that a 12-month waiting period is in place for coverage related to suicide.

What waiting periods apply to this policy?Trish Lee2023-11-17T09:40:25+02:00

What waiting periods apply to this policy?

6 months waiting period applies to any pre-existing condition/natural death.
A 12-month waiting period applies for suicide
No waiting periods apply to accidental death.

When will my claim not be processed?Trish Lee2023-11-17T09:40:33+02:00

When will my claim not be processed?

Where your policy is in arrears.

Where you have not provided all the required documentation.

Where the dependant you are claiming for no longer meets the eligible spouse/dependant definition.

When will cover cease on this policy?Trish Lee2023-11-17T09:40:41+02:00

When will cover cease on this policy?

On the death of the principal insured.

When you do not pay your premium for 2 consecutive months.

Non-Life

How does Gap Cover work?Site Admin2023-11-17T09:26:25+02:00

How does Gap Cover work?

Medical schemes have set limitations, co-payments and medical tariffs that dictate what they will pay for and how much they will pay when a medical scheme member is treated in hospital. This policy aims to cover you for the amounts owed to the specialists and hospitals once the medical scheme has settled the accounts and there are still amounts owing.
But these payments are also subject to limits as per the amount shown, per type of cover.

Some of these payments may also be due at time of hospital admission. These amounts would normally be covered by the principal insured but can be claimed back once the medical scheme statement is available and shows the amount paid by the principal insured.

Will it cover all the shortfalls I have on my medical scheme cover?Site Admin2023-11-17T09:29:42+02:00

Will it cover all the shortfalls I have on my medical scheme cover?

No. It will only cover in-hospital procedures, and certain day admission procedures in day-clinics (as defined), provided none of these are as a result of any of the exceptions listed.

Outpatient procedures are only covered when accompanied by your medical scheme’s authorisation and also included in the “Outpatient Table” which is available under the Gap Benefits.

Cover for all medical scheme shortfalls is limited to a maximum of R198 000 per person per annum.

For the first three years following inception of a contract, there is a limit of R30 000 (per person) in respect of the combined shortfall claims for hip and knee replacements or procedures from the sub-limit and gap benefit.

Who may be covered under this policy?Site Admin2023-11-17T09:26:09+02:00

Who may be covered under this policy?

You, your spouse or life partner and your biological children and legally adopted or fostered children.

Permanently disabled children are not bound by this age restriction.

No grandchildren will be covered unless you are able to prove that they are 100% financially dependent on you and in the absence of their own parents.

How do I submit a claim?Site Admin2023-11-17T09:26:02+02:00

How do I submit a claim?

Contact our Customer Care Centre on 0860 633 929, email customercare@medway.co.za or send us a WhatsApp message.

Based on the information you provide, you will be emailed the appropriate forms along with detailed requirements.

Provided you submit all the correct information, your claim will be processed within the time frames stipulated.

How long does it take to process and pay my claim?Site Admin2023-11-17T09:27:34+02:00

How long does it take to process and pay my claim?

A complete Gap Claim (this includes a 100% fully completed claim form plus all the required supporting documentation), is processed within 10 working days.

What are the general conditions?Site Admin2023-11-17T09:25:46+02:00

What are the general conditions?

Cooling-off period of 31 days, from policy inception, is allowed i.e., within this period, you may cancel and get refunded.

Notice to terminate is 31 days.

Premiums are paid monthly in advance.

Any premium received after 40 days of usual strike date, will result in no cover for that month.

No refunds are due in the case of the cancellation of a policy, other than in the cooling-off period.

What are some of the general exclusions on my policy?Site Admin2022-05-30T10:28:05+02:00

What are some of the general exclusions on my policy?

Any bodily injury or sickness as a consequence of:

War; military action; rebellions and revolutions
Nuclear weapons or nuclear materials
Attempted suicide and self-injury
Drug and alcohol abuse
Active military duty (excluding HECB Cover)
Participation in aviation or motorised speed testing
Routine physical or diagnostic procedures
Anything relating to cosmetic surgery and obesity treatment/surgery
Depression; insanity; mental stress and psychotic disorders
Fraudulent submissions

What waiting periods apply to this policy?Site Admin2022-05-30T10:28:35+02:00

What waiting periods apply to this policy?

There is no general waiting period that applies to this policy. Your benefits are available from day 1 that your policy commences. (However, a general waiting period of 3 months may be applied at the discretion of the underwriter.)

A standard waiting period of 12 months applies to any pre-existing medical condition diagnosed or treated prior to you applying for this policy. (All applicable conditions must be declared on your application form).

Pregnancy is not covered for the first 12 months.

A 6 month waiting period applies for any death by natural cause or pre-existing conditions, whereas a 12 month waiting period applies for death as a result of suicide.

No waiting period applies for accidental death or accident related treatment.

No waiting period applies to the Premium Waiver benefit.

When will my claim not be processed?Site Admin2022-05-30T10:29:05+02:00

When will my claim not be processed?

Where your policy is in arrears.

Where the insurer has investigated and found that the condition relating to the claim was not disclosed at time of application and is considered a nondisclosure, in which case the policy may be cancelled by the insurer.

Where your medical scheme cover has lapsed or is terminated at the time of the incident, and where you are claiming for medical expenses shortfalls.

Where you are claiming outside the 12 month period that you have in which to claim and/or the claim was not submitted within 6 months of the incident and you do not sufficiently justify the lateness of submission.

Where you have not provided all the required documentation.

Where you have provided false information, in which case the policy may be cancelled by the insurer.

Where the dependant you are claiming for no longer meets the eligible spouse/dependant definition.

Where your medical scheme has rejected the claim.

Where you are claiming for a benefit that is only applicable in the case of accidental injury and you did not have an accident.

Where you are claiming for accidental injury and the ICD10 codes are not listed as accident codes.

When will cover cease on this policy?Site Admin2022-05-30T10:29:36+02:00

When will cover cease on this policy?

When you do not pay your premium for 2 consecutive months.

When the principal insured attains the age stated as the cut-off age for the benefit.

In some cases, age limits may be applied to other insured persons too.

On the death of the principal insured.

When you no longer have medical aid cover.

What should I do if I currently have gap cover but I am wanting to switch this policy to Medway?Site Admin2022-05-30T10:30:03+02:00

What should I do if I currently have gap cover but I am wanting to switch this policy to Medway?

Your family rightly deserves the best cover. That’s why we recommend that you Click Here to have a Medway consultant contact you, to ensure that the reason you are changing is because this policy offers you better benefits matching your and/or your family’s medical and financial needs.

If this is the case, you will then need to ensure that you cancel your existing policy and allow for this policy to commence without any overlap (as it is against the law to have duplicate gap cover).

The importance of gap cover

You may think your medical scheme provides full cover. Sadly, this wont always be the case.

I have medical scheme cover. Why do I need gap too?

To help you select a gap plan that meets your most critical priorities and budget, the information below outlines where typical shortfalls in your medical scheme may occur:

Medical scheme tariffs

There may be times when the majority of your bill is not covered by your medical scheme. Gap pays the difference up to 600%.

What is a PMB?

Innovative procedures & treatments your doctors may recommend, may be excluded from your medical cover.

Non-PMB Treatments

It may surprise you to discover that casualty ward expenses are excluded from hospital plan cover.

Casualty ward expenses

If you hit a sub-limit, you may have to forgo further treatment unless you can cover the costs yourself.

Sub-limits

Co-payments

You may not be free to choose the private hospital facility you wish to visit.

Non-designated service providers penalty

Our gap cover plans start from R365 p/m for the whole family

Pick your cover to meet your budget and most critical priorities.

I have medical scheme cover.
Why do I need gap too?

Our gap cover plans start from
R365 p/m for the whole family