Combo Gap Plus

SUMMARY OF COVER

BENEFITS

This Policy may only be marketed to persons who belong to a Medical Aid Scheme.

Premium Waiver

 In the event the principal member is unable to work for a period of more than 30 days due to a motor vehicle accident, the underwriters shall pay the monthly Medical Aid membership fee for each month, or part thereof, that the principal member is unable to work up to a maximum of

12 months.

Body Repatriation

 In the event an Insured dies, due to a motor vehicle accident, underwriters shall pay for the cost of transporting the body of the deceased Insured to the normal place of residence up to a maximum cost of R20 000 (per policy).

Motor Hijack

 In the event an Insured is directly involved in the forceful hijacking of a motor vehicle, and/or threat thereof, the underwriters shall pay a lump sum of R5 000 (per policy).

Trauma Counselling

 In the event an Insured is directly involved in an act of violence, underwriters shall pay a stated benefit of R400 per counselling session undertaken by the Insured up to a maximum of R5 000 per Insured p.a.

1. An act of violence will include assault, robbery, attempted rape and shall include a motor vehicle accident in which another party dies.

2. This act of violence must be reported to the Police and a case number obtained.

Hospital Co-payments

 Underwriters will cover a hospital co-payment as reflected by the Insured’s Medical Aid Scheme Option. This Insured benefit shall be restricted to the co-payment required by the Insured before treatment is authorised by the Insured’s Medical Aid Scheme. This benefit does not cover procedures not authorised by the Insured’s Medical Aid Scheme, nor cover benefits restricted or limited by the Insured’s Medical Aid Scheme. This benefit is restricted to R15 000.

 Dental Surgery Co-payment Restrictions

These benefits are restricted to the following levels, subject to the procedure being authorised by the Insured’s Medical Aid Scheme Option.

Hospital Gap Plus/Premier Cover

 Underwriters will cover in-hospital costs, which qualify under the H&A Health Rate, which are not covered to their full extent by the member’s Medical Aid Scheme. These shortfalls shall be covered up to a maximum of 4 times the ruling H&A Health Rate. In order for benefits to be payable the Insured must be hospitalised and the benefits must qualify in terms of the Insured’s Medical Aid Scheme and the Policy terms and conditions.

In order to illustrate this aspect the following applies:

a) An Insured may not elect to upgrade bed facilities from a General Ward to a Private Ward/ Room and expect the Policy to cover such costs.

b) An Insured may not be hospitalised for treatment not authorised by their Medical Aid and expect the Policy to cover such costs.

c) Costs in excess of the Medical Aid Sub-limits are also not covered by the Policy. These may include restrictions to items such as prosthesis or organ transplant.

Benefits are limited to R1 000 000.00 per family per annum.

PREMIUMS

• The premiums are inclusive of 20% broker commission.

• Premiums payable by debit order will attract a monthly debit order fee of R10.

• Premiums payable by the Employer by way of a debit order will require the completion of a Company Debit Order Form.

• Large Corporate clients may elect to pay premiums by way of EFT (minimum monthly premium must exceed R7 500 to qualify).

Combo Gap Plus Cover Plan: R105.00 p.m. per principal member

This option covers the applicable in-hospital costs from 2 times the Scheme rate up to a maximum of 4 times H&A Health Rate. The additional benefits of Premium Waiver, Body Repatriation, Motor Hijack and Hospital Co-payments are included.

Combo Gap Premier Cover Plan: R125.00 p.m. per principal member

This option covers the applicable in-hospital costs from 1 (or 1.5) times the Scheme rate up to a maximum of 4 times H&A Health Rate. The additional benefits of Premium Waiver, Body Repatriation, Motor Hijack and Hospital Co-payments are included.

CLAIMS

Premium Waiver

 The principal member is required to submit proof of Medical Aid membership fees, plus proof of absence from work due to a motor vehicle accident (on a month to month basis).

Body Repatriation

 Proof of location of the accident and proof of normal residence to be supplied.

Trauma Counselling

 Police report confirming that the case has been registered with a case number.

 Trauma counselling report and associated accounts.

Motor Hijack

 Proof of the forceful hijacking, and/or threat thereof, to be supplied by the Police authorities.

Hospital Combo Gap Plus/Premier Cover (and co-payment benefit)

 Where the Insured person has received pre-authorisation from their Medical Aid for in-hospital treatment which is not excluded in terms of the Combo Gap Plus/Premier Cover Plan exclusions, a claim form should be submitted for payment of benefits.

In order to submit a claim for benefits, the Insured is required to:

a) Complete a Claim Form.

b) Submit a copy of their Medical Aid Remittance Advice illustrating the shortfall (co-payment)

c) Submit copies of the Hospital account, as well as the accounts for the in-hospital attending specialists.

Payments will be made directly into the Insured’s bank account.

UNDERWRITING CRITERIA

Voluntary groups/persons shall have a 12-month pre-existing condition exclusion, a 12-month waiting period for maternity and a 30-day waiting period for all other benefits. Compulsory groups in excess of 35 employees shall be considered for the waiver of pre-existing exclusions and waiting periods.

Downloads
Combo Gap Plus - Summary of Cover	262 Kb

COMBO GAP PLUS/COMBO GAP PREMIER COVER PLAN

Benefit	Procedure
R1 300	Dental treatment in a private hospital persons 13 years and younger
R3 300	Dental treatment in a private hospital persons older than 13 years
R650	Dental treatment in a day clinic persons 13 years and younger
R2 200	Dental treatment in a day clinic persons older than 13 years

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