Got questions?
Understanding Gap Cover
1Is Gapwise a Medical Aid?
No. GapWise is not a medical scheme. It is a stated benefit policy in terms of the short-term Insurance Act 53 of 1998.
2Why do I need gap cover?
Gap cover is a short-term insurance policy which provides shortfall cover where medical expenses are substanially higher than the medical aid rate, providing you with a risk benefit option, so you don't have to go into debt.
3What are medical scheme rates (MSR)?
Medical scheme rates (MSR) are the amounts a medical aid scheme is prepared to pay for specific treatments and procedures. They are usually 2% to 5% higher than the guideline prices published in the RPL, but differ from scheme to scheme.
Entry-level medical aid options usually pay for in-hospital expenses at 100% of the scheme rate. More expensive, comprehensive plans pay up to 300% of the scheme rate, but therein lies the rub.
4What is co-payment cover?
Co-payment cover is insurance that covers part of, or all of the cost of co-payments to your medical aid scheme. It is generally a fixed amount that your medical aid requires you to pay for a specific medical treatment or procedure, out of your own pocket.
5Can I replace my medical aid with Gapwise?
No. Gapwise can only be used as an add-on to your existing medical scheme. You must first claim from your medical scheme before claiming from GapWise.
6What are the In-Hospital benefits on the Comprehensive Plan?
Gap Cover: Additional 500%.
Co-Pay Fee: Up to R10 000 per admission.
Admission Fee: Up to R3000 per admission.
Penalty Fee: R3000 per admission, R6000 per annum.
Appliance Benefit: R3000 per annum for selected appliances.
ER Benefits: R3000 per annum.
Hospital Account: R1000 per claim, 3 claims allowed per annum.
Day Hospitals: Subject to Overall Annual Limit.
Co-Pay Fee: Up to R10 000 per admission.
Admission Fee: Up to R3000 per admission.
Penalty Fee: R3000 per admission, R6000 per annum.
Appliance Benefit: R3000 per annum for selected appliances.
ER Benefits: R3000 per annum.
Hospital Account: R1000 per claim, 3 claims allowed per annum.
Day Hospitals: Subject to Overall Annual Limit.
7What are the In-Hospital benefits on the Ultra Plan?
Gap Cover: Additional 500%.
Co-Pay Fee: Up to R15 000 per admission.
Admission Fee: Up to R5000 per admission.
Penalty Fee: R5000 per admission, R10 000 per annum.
Appliance Benefit: R5000 per annum for selected appliances.
ER Benefits: R5000 per annum.
Hospital Account: R1500 per claim, 3 claims allowed per annum.
Day Hospitals: Subject to Overall Annual Limit.
Sub-Limit Enhancer: Internal prosthesis, CT & MRI Scans, R20 000 per claim, R40 000 per annum.
Co-Pay Fee: Up to R15 000 per admission.
Admission Fee: Up to R5000 per admission.
Penalty Fee: R5000 per admission, R10 000 per annum.
Appliance Benefit: R5000 per annum for selected appliances.
ER Benefits: R5000 per annum.
Hospital Account: R1500 per claim, 3 claims allowed per annum.
Day Hospitals: Subject to Overall Annual Limit.
Sub-Limit Enhancer: Internal prosthesis, CT & MRI Scans, R20 000 per claim, R40 000 per annum.
8What are the Day-to-Day benefits on the Comprehensive Plan?
Primary Care Benefit: Gap Portion of consultation limited to 3 consultations for:
- General Practitioners @R200 per consultation
- Dental Practitionaers @ R200 per consultation
- Alternative Care @ R300 per consultation.
Preventative Care Benefit: Gap Portion for Preventative Treatments limited to R1 000 per claim, 3 claims per annum.
Specialist Consultations: Gap Portion of consultation @ R1 000 per consultation, 3 claims per annum.
- General Practitioners @R200 per consultation
- Dental Practitionaers @ R200 per consultation
- Alternative Care @ R300 per consultation.
Preventative Care Benefit: Gap Portion for Preventative Treatments limited to R1 000 per claim, 3 claims per annum.
Specialist Consultations: Gap Portion of consultation @ R1 000 per consultation, 3 claims per annum.
9What are the Day-to-Day benefits on the Ultra Plan?
Primary Care Benefit: Gap Portion of consultation limited to 3 consultations for:
- General Practitioners @ R350 per consultation
- Dental Consultation @ R350 per consultation
- Alternative Care @ R450 per consultation
Preventative Care Benefit: Gap Portion for preventative treatments limited to R1 500 per claim, 3 claims per annum.
Specialist Consultations: Gap Portion of consultation @ R1 500 per consultation, 3 claims per annum.
- General Practitioners @ R350 per consultation
- Dental Consultation @ R350 per consultation
- Alternative Care @ R450 per consultation
Preventative Care Benefit: Gap Portion for preventative treatments limited to R1 500 per claim, 3 claims per annum.
Specialist Consultations: Gap Portion of consultation @ R1 500 per consultation, 3 claims per annum.
10What Added Benefits are on a Comprehensive Plan?
Accidental Death:
- Principal: R7,500
- Adult Dependant: R5,000
- Child Dependant: R3,000
Gap Premium Waiver: 12 month premium waiver when premium payer is forcibly retrenched, becomes totally and permanently disabled or passes away.
Medical Aid Contribution Cover: 6 months payment toward your Medical Aid contributions up to R3,000 per month upon the death or total and permanent disability of the premium payer.
- Principal: R7,500
- Adult Dependant: R5,000
- Child Dependant: R3,000
Gap Premium Waiver: 12 month premium waiver when premium payer is forcibly retrenched, becomes totally and permanently disabled or passes away.
Medical Aid Contribution Cover: 6 months payment toward your Medical Aid contributions up to R3,000 per month upon the death or total and permanent disability of the premium payer.
11What Added Benefits are on an Ultra Plan?
Accidental Death:
- Principal: R15,500
- Adult Dependant: R10,000
- Child Dependant: R5,000
Gap Premium Waiver: 12 month premium waiver when premium payer is forcibly retrenched, becomes totally and permanently disabled or passes away.
Medical Aid Contribution Cover: 6 months payment toward your Medical Aid contributions up to R5,000 per month upon the death or total and permanent disability of the premium payer.
- Principal: R15,500
- Adult Dependant: R10,000
- Child Dependant: R5,000
Gap Premium Waiver: 12 month premium waiver when premium payer is forcibly retrenched, becomes totally and permanently disabled or passes away.
Medical Aid Contribution Cover: 6 months payment toward your Medical Aid contributions up to R5,000 per month upon the death or total and permanent disability of the premium payer.
12What are the Dental Benefits on the Comprehensive Plan?
3 claims per beneficiary @ R200 per consultation.
13What are the Dental Benefits on the Ultra Plan?
3 claims per beneficiary @ R350 per consultation.
Understanding the Claims process
1How do I claim?
We are working on a handy online claims process, but for now you need to download the Gapwise Claim Form from our Downloads page, complete it and email it to claims@sirago.co.za.
2Is there a waiting period before I can claim?
A Standard 3-month waiting period applies.
Pre-existing conditions may be excluded for a minimum period of 12 months.
Pre-existing conditions may be excluded for a minimum period of 12 months.
3What are the exclusions?
Policy specific exclusions apply. Please see your policy document for details.
Understanding my Policy
1What are the price structures?
Comprehensive Plan from R140 per month.
Ultra Plan from R179 per month.
<Click Here for an instant quotation>
Ultra Plan from R179 per month.
<Click Here for an instant quotation>
2Who is covered?
All policies have one Principal and Dependants can be added to the policy where there is insurable interest.
3What are the terms and conditions?
Please see our Terms and Conditions for relevant information or contact your advisor for a thorough consultation.
4What underwriting will be applied to new policies?
Please see our Terms and Conditions for relevant information or contact your advisor for a thorough consultation.
5What are the Cancer Benefits on a Comprehensive Plan?
Initial Diagnosis: R10,000.
Cancer Shortfall Cover: R164,000 per annum for any Gap or Co-Payment paid from the oncology benefit as part of your oncology treatment plan. R60,000 Sub-Limit on oncology Co-Payments.
Cancer Top-Up: R50,000 per annum where Rand limits on Medical Aid has been reached.
Reconstructive Benefit: 200% Gap Cover for reconstructive surgery on effected breast and up to R15,000 for reconstruction of unaffected breast.
Cancer Shortfall Cover: R164,000 per annum for any Gap or Co-Payment paid from the oncology benefit as part of your oncology treatment plan. R60,000 Sub-Limit on oncology Co-Payments.
Cancer Top-Up: R50,000 per annum where Rand limits on Medical Aid has been reached.
Reconstructive Benefit: 200% Gap Cover for reconstructive surgery on effected breast and up to R15,000 for reconstruction of unaffected breast.
6What are the Cancer Benefits on an Ultra Plan?
Initial Diagnosis: R20,000.
Cancer Shortfall Cover: R164,000 per annum for any Gap or Co-Payment paid from the oncology benefit as part of your oncology treatment plan. R100,000 Sub-Limit on oncology Co-Payments.
Cancer Top-Up: R100,000 per annum where Rand limits on Medical Aid has been reached.
Reconstructive Benefit: 300% Gap Cover for reconstructive surgery on effected breast and up to R25,000 for reconstruction of unaffected breast.
Cancer Shortfall Cover: R164,000 per annum for any Gap or Co-Payment paid from the oncology benefit as part of your oncology treatment plan. R100,000 Sub-Limit on oncology Co-Payments.
Cancer Top-Up: R100,000 per annum where Rand limits on Medical Aid has been reached.
Reconstructive Benefit: 300% Gap Cover for reconstructive surgery on effected breast and up to R25,000 for reconstruction of unaffected breast.
7What happens if the debit order date falls on a weekend or on a public holiday?
Depending on the chosen payment day and on which day of the weekend or public holiday it falls, the payment will be debited on the business day immediately preceding or following the selected payment date.
8When is payment due?
Premiums will be collected via debit order on selected days.
9What is the medical scheme rate?
Medical scheme rates (MSR) are the amounts a medical aid scheme is prepared to pay for specific treatments and procedures. They are usually 2% to 5% higher than the guideline prices published in the RPL, but differ from scheme to scheme. Entry-level medical aid options usually pay for in-hospital expenses at 100% of the scheme rate. More expensive, comprehensive plans pay up to 300% of the scheme rate, but therein lies the rub.
10Do you cover planned Prescribed Minimum Benefit (PMB) procedures?
As set out by the Council of Medical scheme, medical schemes should pay for all PMB procedures.
11Can my family be on more than one medical aid scheme but under one GapWise policy?
Absolutely. Families on multiple medical schemes can be covered under one Gapwise policy.