FREQUENTLY ASKED QUESTIONS ABOUT GAP COVER
HOW DOES MEDICAL EXPENSE SHORTFALL COVER WORK?
A Medical Expense Shortfall is the difference between what medical service providers
(e.g. Doctors, basic and specialised Radiology, Pathology, Specialists) charge and what Medical Schemes pay for the treatment performed in hospitals and day clinics, provided that it is paid from the Hospital Benefit of your Medical Scheme.
Medical Expense Shortfall Cover will boost your Medical Aid rate, helping you with this shortfall!
Below is an example of a claim for a Hip replacement
|MEDICAL SERVICE PROVIDER||AMOUNT CHARGED BY THE MEDICAL SERVICE PROVIDER||AMOUNT PAID BY MEDICAL SCHEME||AMOUNT PAID BY TURNBERRY|
|Surgeon||R17 053||R6 021||R11 032|
|Anaesthetist||R8 256||R2 402||R5 854|
|Total paid by Turnberry||R16 886|
HOW DOES CO-PAYMENT COVER WORK?
A co-payment or deductible is an upfront amount that needs to be paid to the hospital/day clinic /radiologist before undergoing certain procedures, as specified by your Medical Scheme
When you experience a co-payment for a procedure or scan (as specified by your Medical Scheme) you would need to pay for the co-payment up-front and then claim the amount back from your Easy Gap policy (provided that the plan you selected offers a co-payment benefit)
If your Medical Scheme pays for co-payments from your day to day benefits you may still claim the amount back from your Easy Gap policy
HOW DOES NON-DSP HOSPITAL PENALTY COVER WORK?
Should you choose to go to a hospital or day clinic outside of your Medical Scheme’s Hospital Network/Designated Service Providers, you would be liable for a portion of the account,as specified by your Medical Scheme.
Johnny’s Medical Scheme stipulates that he needs to go to hospital X, if :
He chooses to go to another hospital he would need to pay the first R8 000 of the hospital account. Johnny chooses to go to hospital Y and pays the R8 000 and then claims it back from his Easy Gap Complete policy
HOW DOES SUB-LIMIT COVER WORK?
When a Medical Scheme will only pay for a certain procedure, prosthetic device or scan up to a specified limit, this is a sub-limit.
Joe gets admitted to hospital for a hip replacement. After the procedure he notices that the cost of the prosthetic hip was R60 000, but his Medical Scheme only paid R50 000 towards the prosthetic hip, leaving him liable for R10 000.
Luckily for Joe, he has an Easy Gap policy that offers sub-limit cover of R20 000 per admission.
Therefore Joe can submit the account to Easy Gap to pay the R10 000 the difference from his Easy Gap Complete Policy.
HOW DOES TRADITIONAL CANCER TREATMENT COVER WORK?
If you have depleted your Cancer benefit on your Medical Scheme, you may become liable for co-payments or the full cost of any further Cancer treatment, as specified by your Medical Scheme.
Kathy has finished her R250 000 Cancer benefit available to her on her Medical Scheme and now she is liable for the full cost of her Cancer treatment.
Kathy still needs to undergo chemotherapy sessions. Luckily, she has a Easy Gap Complete policy and she can submit the cost of her further chemotherapy sessions to Easy Gap
Deon has finished his R250 000 Cancer benefit available to him on his Medical Scheme and still needs to undergo chemotherapy. His Medical Scheme will pay for 80% of the account for his chemotheraphy . Deon is glad he listended to his Financial Advisor and took our a Easy Gap Complete policy , now be can submit the account to Easy Gap.
HOW DOES BIOLOGICAL CANCER DRUG COVER WORK?
When you require treatment with Biological Cancer Drugs your Medical Scheme may only pay for them up to a certain limit.
John’s Medical Scheme paid for the Biological Cancer Drugs he required up to a limit , thereafter he was liable for the full cost of his Biological Cancer Drugs.
John was grateful that he took out a Easy Gap Complete policy and he submitted the rest of the account for his Biological Cancer Drugs to Easy Gap
- A 3-month general waiting period appliers to all benefits, with exception of benefits providing cover up to 600% should the commencement of the Policy be in line with the commencement date of the Medical Scheme. Accidents wll be covered with in the 3 month general waiting period.
- A 10-month waiting period on pregnancy/childbirth
- A 12-month waiting period on/investment, treatment or surgery for: hysterectomy (except where malignancy can be proven) , hysteroscopies, endometriosis, ovarian cysts and fibroids ( myomectomy), muscular-skeletal, tonsillectomy, myringotomy, grommets, adenoids, wisdom teeth, hernia, cataracts, gastroscopies, colonoscopiers, cancer, nasal and sinus
|Treatment date of the claims is within:||Benefits for childbirth will be capped at :|
|First 12 months of the Policy||R8 000 per event|
|13-24 months of the Policy||R12 000 per event|
|25+ months of the Policy||Subject to the Overall Annual Limit of the Policy|
COMPARISON OF BENEFITS
Overall Annual Limit (OAL) R150 000 per insured per annum
|PRIVATE RATE COVER||Increases the Medical Aid rate up to 600%. Subject to OAL||Increases the Medical Aid rate up to 500%. Subject to OAL||Increases the Medical Aid rate up to 350%. Subject to OAL and an excess of R350 per event|
|CO-PAYMENT COVER||R75 000 per admission per insured.Subject to OAL||R50 000 per admission per insured.Subject to OAL||Not applicable|
|NON-DSP HOSPITAL PENALTY COVER||R9 000 per admission.Limited to 1 claim per family per annum,subject to the OAL||R5 000 per admission.Limited to 1 claim per family per annum,subject to the OAL||Not applicable|
|SUB-LIMIT COVER||R20 000 per admission per insured.Subject to OAL||R15 000 per admission per insured.Limited to R50 000 per family per annum, subject to OAL||Not applicable|
|IN-HOSPITAL AND OUT-OF-HOSPITAL BENEFITS|
|TRADITIONAL CANCER COVER||Pays for treatment in a private facility,including sub-limits,deductibles or co-payments related to cancer treatment (R200 000 excess).Subject to OAL||Not applicable||Not applicable|
|BIOLOGICAL CANCER DRUG COVER||Provides cover for Biological Cancer Drugs when the Medical Scheme imposes a sub-limit. Subject to OAL||Not applicable||Not applicable|
|CO-PAYMENTS FOR MRI,CT AND PET SCANS||R75 000 per admission per insured.Subject to OAL||R50 000 per admission per insured.Subject to OAL||Not applicable|
|SUB-LIMIT COVER FOR MRI,CT AND PET SCANS||R20 000 per admission per insured.Subject to OAL||Not applicable||Not applicable|
|CASUALTY BENEFIT (ACCIDENTS ONLY)||R12 000 per admission per insured.Subject to OAL||R6 500 per event per insured.Subject to OAL||R3 000 per event per insured.Subject to OAL and an excess of R350 per event|
|CANCER DIAGNOSIS BENEFIT||Once off payment of R20 000 for first diagnosis of cancer,provided that the memeber is on an approved oncology treatment plan||Not applicable||Not applicable|
|MEDICAL SCHEME CONTRIBUTION WAIVER||Up to R5 500 per month for 6 months,covers death or permanent and total disability(due to an accident),of the Medical Scheme contribution payer||Up to R5 500 per month for 6 months,covers death or permanent and total disability(due to an accident),of the Medical Scheme contribution payer||Up to R5 500 per month for 6 months,covers death or permanent and total disability(due to an accident),of the Medical Scheme contribution payer|
|GAP PREMIUM WAIVER||Pays the premium for your EasyGap Complete policy for 6 months;covers death or permanent and total disability as a result of an accident,of the contribution payer||Pays the premium for your EasyGap Boost policy for 6 months;covers death or permanent and total disability as a result of an accident,of the contribution payer||Pays the premium for your EasyGap Launch policy for 6 months;covers death or permanent and total disability as a result of an accident,of the contribution payer|
|PERSONAL ACCIDENT BENEFIT||R25 000 per insured on the policy,covers accidental death or permanent and total disabilty||Not applicable||Not applicable|
|INTERNATIONAL TRAVEL COVER||R5 000 000 per insured||5 000 000 per insured||5 000 000 per insured|