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Gap Plus/Premier Cover Plan
PRODUCT SPECIFICATION
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, underwriters shall pay the monthly Medical Aid membership fee, for each month or part thereof, 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, underwriters shall pay a lump sum of R5 000 (per policy)
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:
- 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
- An Insured may not be hospitalised for treatment not authorised by their Medical Aid and expect the Policy to cover such costs
- Costs in excess of the Medical Aid Sub-
limits are also not covered by the Policy - Benefits are restricted 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 R10.00.
- Premiums payable by the Employer by way of 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 R7500 to qualify).
- Gap Plus Cover Plan: R76-
00 p.m. per principal member
- This option covers the applicable in-
hospital costs from 2 times H&A Health Rate up to a maximum of 4 times H&A Health Rate. The additional benefits of Premium Waiver, Body Repatriation and Motor Hijack are included.
- Gap Premier Cover Plan: R98-
00 p.m.
This option covers the applicable in-
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
Motor Hijack
- Proof of the forceful hijacking, and/or threat thereof, to be supplied by the Police authorities
Hospital Gap Plus/Premier Cover
- Where the insured person has received pre-
authorisation from their Medical Aid, for in- hospital treatment which is not excluded in terms of the 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:-
- Complete a Claim Form
- Submit a copy of their Medical Aid Remittance Advice illustrating the short-
fall - 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
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Downloads | |
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Application Form |
65 Kb |
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Summary of Cover |
439 Kb |
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Policy Wording |
60 Kb |