host | MedGap

Benefits

Know your benefits

Gap cover is now a great deal easier to buy with the exclusive Bonitas Medgap offer. Guard yourself against medical expense shortfalls during hospitalisation

What is GAPCOVER

Did you know that specialists and other service providers often charge more than the amount covered by medical aid schemes? This is where GAP cover is your saving grace… Your MedGap GAP cover policy will give you peace of mind by covering the shortfall that you are liable for – saving you from extra expenses.

Medgap Product Offering For 2020

MedGap is a specially designed short-term insurance product, which provides cover for medical expense shortfalls (“gaps”) should you or a loved one need to undergo surgery whilst in hospital or a medical procedure on an outpatient (out-of-hospital) basis.

Medgap Primary

– Shortfall benefit – Co-payment benefit

Medgap Supreme

– Shortfall benefit – Co-payment benefit – Cancer benefit – Internal prosthesis benefit – Accidental death and disability – Casualty benefit – Trauma counseling

Medgap Millennial

Discounted rates up to 27% to Bonitas Member. This is exclusive cover for young individuals Only a single Insured person Offering both the Primary and Supreme options at a competitive rate.

What is covered

Section A: Medical Expense Shortfall Benefits 22 (Under this section, a maximum of R157 000 can be paid per Insured Person per policy year)

	Supreme	Primary
Beneﬁt for shortfalls in medical practitioner costs (shortfall cover)
Beneﬁt for co-payments applied by your medical scheme for certain procedures
Beneﬁt for Co-payments levied by your medical scheme on oncology treatment programmes
OR
Oncology extender beneﬁt for exceeded medical scheme oncology beneﬁt limits
Lump sum shortfalls for internal prosthesis costs
Beneﬁt for shortfalls in emergency casualty costs due to an accident
Lump Sum Beneﬁts
Lump sum beneﬁt for ﬁrst time, minimum-stage cancer diagnosis
Lump sum beneﬁt for accidental death and permanent total disability
Trauma counselling beneﬁt
Violent crime beneﬁt
Premium waiver beneﬁt
Baby bump beneﬁt

Benefit highlights

Subject to a R165 000 Sublimit Per Annum

Co-Payments

Internal Prosthesis

Oncology

Casualty

Additional Benefits

Lumpsum Cancer

Accidental Lumpsum

Trauma Counselling

In hospital specialist Shortfall

Please click the button for detailed brochure of benefits

Download benefits brochure

MedGap Primary

– Shortfall benefit – Co-payment benefit

MedGap Supreme

– Shortfall benefit – Co-payment benefit – Cancer benefit – Internal prosthesis benefit – Accidental death and disability – Casualty benefit – Trauma counseling

MatchPay benefit increases to 2.5 times for:

– Obstetrics & Gynaecology – Cardiothoracic Surgery – Neurology

Section B: Lump Sum Benefits

	Supreme	Primary
Lump sum benefit for first time, minimum-severity cancer diagnosis
Lump sum benefit for personal Accidental Death and Permanent and Total Disability
Trauma counselling benefit

Section A: Medical Expense Shortfall Benefits

(under this section, a maximum of R157 000 can be paid per insured Peron per policy year)

	Supreme	Primary
Benefit for shortfalls

If you are admitted into hospital for a procedure to treat a disease, an illness or a bodily injury and this procedure is performed by a registered medical practitioner while you are in hospital, we will cover you for the shortfall between what the medical practitioner has charged you and what your medical scheme has paid for the procedure. The maximum amount that we will pay towards this shortfall is calculated as 2x (or 200% of) the amount paid by your medical scheme, up to the value of the actual shortfall.

Specific Conditions

We will only cover you for any shortfall if the following applies to your claim:

The medical scheme option that you have selected includes cover under your major medical benefit for the Procedure that you are claiming for; and

Your medical scheme pays the first portion of each Service Code on the claim from your major medical benefit; and

You are paying for any shortfall from your medical savings account OR in cash; and

Your cover starts with us and the relevant waiting period has expired before the date of admission into Hospital during which the Procedure giving rise to your claim occurs.

If your medical scheme has not paid any portion of your claim from your major medical benefit due to your having depleted that portion of cover, your benefit amount will be calculated as 2 times the amount that your medical scheme would have paid. If this information is unavailable, we reserve the right to calculate an industry-related (MeGap) tariff that will be applied to the calculation of the amount payable to you. It will be your responsibility to provide enough evidence from your medical scheme that your major medical benefit has been depleted.

Benefits for Co-Payments: Certain Procedures

	Supreme	Primary
Benefit for co-payments applied by your medical scheme for certain Procedures

A co-payment is a fixed amount that a medical scheme requires a member to pay for certain procedures. This amount must be paid upfront by the member to the hospital / clinic in which the procedure will take place, and only once this payment has been made, will the medical scheme pay anything towards the cost of the procedure. While there is no limit on how many co-payments MedGap will pay, by law no more than R157 000 per person per year, can be paid towards shortfall benefits (including co-payments). MedGap will only cover co-payments that are applied by a medical scheme for certain, named procedures. Co-payments are commonly applied to radiology scans (MRI, CAT) and specialist referral procedures. Penalty co-payments that are applied by the scheme for not obtaining authorisation or for the use of a non-DSP, will not be covered.

Please click here for the full policy wording document

Benefits for Co-Payments: Oncology

	Supreme	Primary
Benefit for co-payments on oncology Treatment programmes

If you have been diagnosed with cancer you will be required by your medical scheme to register for oncology benefits through an oncology treatment programme with them and the cost for your cancer treatment will be subject to an annual limit. Once you have reached your medical scheme limit, your medical scheme will levy a 20% co-payment on all cancer treatment costs for the remainder of that year. We will cover this 20% co-payment but please remember that by law, your overall limit for shortfalls and co-payments is limited to R 157 000 per Insured Person per policy year.

MedGap will not cover benefits in the following circumstances

Co-payments applied before you reach your oncology treatment benefit limit;

Co-payments applied if you choose to be treated by a service provider that is not contracted with your medical scheme – this is called a non-designated service provider or a non-DSP.

Oncology extender Benefit

	Supreme	Primary
Benefit for shortfalls in internal prosthesis costs

The oncology extender benefit will operate on a similar basis as the oncology co-payment benefit, in that if an insured reaches their medical scheme’s annual oncology treatment limit and the medical scheme offers no further cover for treatment for that year, MedGap will pay the first 20% of treatment costs for the remainder of that year. The remaining 80% of treatment costs will remain for the account of the insured and this cost must have been paid before the 20% benefit will be paid by Medgap. Once again, your overall limit for shortfalls and co-payments is capped at R157 000.

Internal prosthesis

	Supreme	Primary
Benefit for shortfalls in internal prosthesis costs

What is an internal prosthesis?

An internal prosthesis is a device that is placed inside the body during a procedure with the specific purpose of permanently replacing a body part. In other words, a body part is removed and permanently replaced with a prosthesis during surgery.

What will MedGap cover:

If you have an internal prosthesis fitted, your medical scheme may pay the full cost of the prosthesis or it may pay up to a fixed limit. If your medical scheme pays up to a fixed limit and there is a shortfall between the cost of the prosthesis and the fixed limit, we will cover this shortfall up to a maximum amount of R30 000 per policy per year.

MedGap will not cover benefits in the following circumstances

Elective procedures undertaken at a casualty ward

Casualty ward visits due to Illness

Casualty ward claims in which the first cost is not paid by your medical scheme

MedGap will not cover benefits in the following circumstances

Devices that are placed inside a body to assist with the functioning of a body part (for example, a pacemaker, stents, etc.) are specifically excluded from cover

Any external prosthesis or dental implant.

We will also only cover you for any shortfall under this benefit if the medical scheme option that you have selected includes cover under your major medical benefit for the internal prosthesis that you are claiming for. If your medical scheme option does not include cover for this, we will not provider cover for any shortfall either

Accidental Emergency casualty benefit

	Supreme	Primary
Accidental and Emergency casualty benefit

The purpose of this benefit is to provide financial assistance in an emergency where an insured person requires immediate medical attention and does not have enough cover through their medical aid. It is not intended to be used to cover day-to-day medical expenses such as doctor visits, medication, etc. when an insured’s daily benefits through their medical scheme are depleted.

What will this benefit pay?

This benefit will pay up to 3 casualty visits or R10 000 per family per year, of the costs paid by an insured for a visit to the emergency casualty ward, as a result of an accident.

What does “accident” mean?

The policy wording defines an “Accident” as a sudden, unexpected, violent and visible external event, which is inflicted on you by something other than yourself at an identifiable time and place and that independently of any other cause, directly results in Bodily Injury. This means that unless the visit to the causality ward is as a result of an event that meets all the above requirements, the benefit will not be payable

What does “emergency” mean?

“Emergency” means the necessity to immediately visit a casualty facility due to a bodily injury caused by an accident as defined in the policy, and when failure to do so, may result in loss of life, limb or significant complications.

What are the conditions of cover for this benefit?

This benefit is payable for three casualty visits per policy per year up to a maximum of R10 000.

Your medical scheme must have paid the first portion of the claim for you to be eligible for cover under this benefit.

Eligibility to claim for this benefit is subject to verification that the event was an emergency and due to an accident.

Any portion of the total charges paid by your medical scheme will be deducted from the amount payable to you.

Section B: Lump sum benefits

CANCER

	Supreme	Primary
Lump sum benefit for first time, minimum-severity cancer diagnosis

How much will this benefit pay?

MedGap provides a once-off payment of R15 000 if you are diagnosed with cancer for the first time while you are covered on the policy and you have registered with your medical scheme’s oncology treatment programme. We will also pay you an extra R10 000 if you exceed your medical scheme’s oncology benefit limit for the year or if your medical scheme pays out more than R200 000 for oncology treatment in that same year. You must have at least stage II, regional and malignant cancer to be entitled to the benefit. If you are diagnosed for the first time as having a minimum severity of stage II, local and malignant cancer, we will pay a lump sum of R 5 000. This benefit is payable once in a lifetime per person covered on the policy.

MedGap will not cover benefits in the following circumstances

Any cancer diagnosis that does not meet the minimum severity level of stage II, regional AND malignant;

Any diagnosis which is not the insured’s first cancer diagnosis during their lifetime; and

Skin cancers and cancers diagnosed and treated by primary biopsy only

TRAUMA COUNSELLING

	Supreme	Primary
Lump sum benefit for first time, minimum-severity cancer diagnosis

UNDERSTANDING THE TRAUMA COUNSELLING BENEFIT

MedGap provides cover for trauma counselling to our members and their dependants registered on their policy. The cover provided is as follows: • Up to R750 of the cost of each counselling session, • Up to R25 000 per family per year.

SPECIFIC CONDITIONS

If you are subjected to, or a witness of, an act of violence or a traumatic Accident, we will refund you for counselling fees paid by you as a result of the violence or traumatic Accident. An act of violence includes events such as murder, assault, robbery, rape, kidnapping or hijack which is reported to the police and for which a case number has been obtained

SPECIFIC EXCLUSIONS

The following specific exclusions apply to this benefit: • Counselling that is not undertaken due to an act of violence or a traumatic accident • Counselling that is not provided by a registered counsellor.

DISABILITY

	Supreme	Primary
Lump sum benefit for personal Accidental Death and Permanent and Total Disability

For accidental death this benefit will pay R50 000 for insured persons over the age of 14 (including the principal member, the spouse, adult dependants and child dependants over the age of 14 years), R30 000 for child dependants between the age of 6 and 13 years and R10 000 for child dependants under the age of 6 years, at date of death. For accidental disability this benefit will pay R50 000 for all insured persons. This benefit (either death or disability) will only pay once per person per lifetime.

What does “accidental” mean?

The policy wording defines an “Accident” as a sudden, unexpected, violent and visible external event, which is inflicted on you by something other than yourself at an identifiable time and place and that independently of any other cause, directly results in Bodily Injury. This means that unless the death or disability is as a result of an event that meets all of the above requirements, the benefit will not be payable

What does permanent, and total disablement mean?

Permanent and Total Disablement means being completely unable to perform any occupation whatsoever, unable to perform any normal daily living tasks (such as eating, dressing, bathing, walking, etc.) yourself and in the opinion of a Medical Practitioner, unlikely to ever recover from disability. This also means that permanent and total disability of a specific body part (for example a leg or arm) does not meet these criteria. The disability must also be diagnosed as totally and permanently disabled within 4 months of the accident.

MedGap will not cover benefits in the following circumstances

Death or disability that is not due to an accident as defined in the policy

Disability that is not permanent and total as defined in the policy.

Disability that is not diagnosed within 4 months of the accident.

What is a waiting period?

As a first-time gap cover applicant you and your family may have a period in which you will have to pay your premiums, but you will not be able to claim any benefits for events that take place during this time. This is called a waiting period and it protects all policy holders by insuring that individuals are not able to make a large claim shortly after joining and then cancelling their cover as this would unfairly result in increased premiums for all policyholders. A waiting period is calculated from (and includes) the first day on which your cover begins.

The waiting periods that could apply to you and your dependants from your 1st day of cover include:

• A 3-month general waiting period. During this period, you will not be able to make any claims. • A 12-month waiting period for any cancer, birth and pregnancy related medical conditions. • A 9-month waiting period for any other pre-existing medical condition including a physical defect, injury, disease or illness that you or any of your dependants have already been diagnosed for or for which care or treatment was recommended or received within 12 months before the 1st day of cover and which would have caused a reasonable person to seek medical advice and/or treatment.

MEDGAP WAITING PERIODS

When will waiting periods apply to my cover?

Compulsory employer group

• If it is a condition of your employment that you have cover with Medigap, no waiting periods will apply to you or your dependants if you join from date of employment.

Voluntary employer group

• If it is not a condition of your employment, but you choose to voluntarily apply for cover as a member of your employer’s group scheme arrangement within 60 days of your employment start date, only you or those dependants that have a pre-existing medical condition on your cover start date, will have the relevant 9-month or 12-month pre-existing medical condition waiting period applied to their cover. • If it is not a condition of your employment, but you choose to voluntarily apply for cover as a member of your employer’s group scheme arrangement more than 60 days after your employment start date, the 3-month general waiting period will apply to you and your dependants and you and/or those dependants that have a pre-existing medical condition on your cover start date, will have the relevant 9-month or 12-month pre-existing medical condition waiting period applied to their cover.

Voluntary individual

• If you apply for cover as an individual, the 3-month general waiting period will apply to you and your dependants, and you and/or those dependants that have a pre-existing medical condition on your cover start date, will have the relevant 9-month or 12-month pre-existing medical condition waiting period applied to their cover.

Will I have waiting periods imposed if I am moving my cover from another insurer

If you are moving your cover from another insurer to Medigap, the above waiting periods will not apply to you and your dependants, if: • For each insured person, there is no break in cover of more than 90 calendar days between the cover termination date of your cover with the other insurer and your cover start date with Medigap. If there is a break of more than 90 days, you and/or your dependants (whichever is applicable) will be subject to the normal Waiting Periods; • For each insured person, you were covered on the other insurer’s policy for more than 12 months – if you and/or your dependants were covered for less than 12 months, you and/or your dependants (whichever is applicable) will carry the remainder of the waiting period over to your new cover with Medigap; and • You and/or your dependants are continuing cover on the same (or a similar) level of cover that you and/or they had with the other insurer.

Should anything be unclear on the benefits for Medgap please refer to the detailed policy wording document which includes terminology explanations.

Please click here for policy wording document

Contact us

Apply for cover

Affiliations

New Business Enquiries

+27 860 102 936

new@medgaponline.co.za

Claim Enquiries:

+27860 102 936

claims@medgapclaims.co.za

General Enquiries

+27 860 102 936

info@medgaponline.co.za

Premium Enquiries:

+27860 102 936

premiums@medgaponline.co.za

MedGap Supreme and Primary Cover (Application form)

MedGap Supreme and Primary Pensioner Cover (Application form)

If you are interested in joining Medgap please sms “Medgap” to 43366 we will phone you back with accredited advice.

MedGap

Exclusively for Bonitas Members

Gap cover is now a great deal easier to buy with the exclusive Bonitas Medgap offer. Guard yourself against medical expense shortfalls during hospitalisation

%

Discounted rates up to 27% to Bonitas Member

Bonitas

Did you know that specialists and other service providers often charge more than the amount covered by medical aid schemes? This is where GAP cover is your saving grace…

As a member you would be personally liable for the difference in cost, which for specialists and other service providers s can add up to a sizeable amount. MedGap offers Bonitas members and their loved ones a specially designed product that provides cover for medical expense shortfalls in the event of hospitalisation involving surgery or medical treatment, as well as for certain procedures performed out-of-hospital. Gap cover is now a great deal easier to buy with the exclusive Bonitas Medgap offer.

New

Millennial

Gap Cover

Ages: over 18 to under 30 years

%

Discounted rates up to 27% to Bonitas Member

This is exclusive cover for

young individuals

Only a single Insured person Offering both the Primary and Supreme options at a competitive rate.

2020 RATES

These rates are exclusive to Bonitas members and are guaranteed for 2020.Our MedGap products offers cover for you, your spouse, your children and your parents that are registered as dependents on your medical scheme and that are eligible for cover at the date of you joining. Millennial is a product for individuals over the age of 18 and under the age of 30. New members cannot join if they are already 30. When a member turns 30 during the year, we will automatically move them to the individual family cover with their renewal in January the following year. Our MedGap Pensioner products offers cover for you only, if you are over the age of 65 at the date of joining.

Benefit highlights

Subject to a R165 000 Sublimit Per Annum