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.
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 R185 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.
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.
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.
A complete claim (this includes a 100% fully completed form plus all the required supporting documentation) will be processed within 10 working days.
A complete funeral claim is processed within 48 working hours.
Dread disease and Non-Medical expenses claims can take up to 20 working days to process as they may involve lengthy investigations.
Claims referred for pre-existing condition investigations and for prescribed minimum benefits will take longer than 10 days, but we will communicate this with you.
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.
Any bodily injury or sickness as a consequence of:
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.
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 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.
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).