Benefits

Internal Prosthesis 

Internal prosthesis costs can become quite expensive, especially if your medical scheme only pays up to a certain amount and you end up having to pay the difference yourself. If you undergo a medical procedure that requires the use of an internal prosthesis to replace a body part and you reach your medical scheme limit for the year, we will pay the shortfall up to a limit of R30 000 per family per year. Stents and pacemakers are covered to a limit of R6 000 per claim event and this aggregates to the R30 000 annual limit.

Internal prosthesis

SupremePrimary
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 fixed limit. If your medical scheme pays up to a fixed limit and there is a shortfall between the costs of the prosthesis and the fixed limit, we will cover this shortfall up to a maximum amount of R30 000 per policy per year. Stents and pacemakers are covered to a limit of R6 000 per claim event and this aggregates to the R30 000 annual limit.

MedGap will not cover benefits in the following circumstances
  • 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 provide cover for any shortfall either
Claiming made easy

If you have given consent for claims data sharing with Guardrisk insurance company the claim will be automatically processed and paid to the member. MedGap wants to make claiming as easy as possible for our clients. It is important to follow the steps below to ensure that your claim is processed within the correct timeframes. You have 4 months from the date of treatment to provide us with written notice of your claim. If any details are missing, or we need more information or documents, we will contact you. If we do this, please send us the outstanding documents within 28 days of our request or we will close your claim until you provide us with the documents we need. If you do not send us these documents within 12 months of your claim event, your claim will prescribe and we will close it permanently.

Steps to follow to submit your claim

1

Complete the applicable section in the online form below, and submit OR download the PDF version of the form, complete and send, with all required documents, to medgapclaims@guardrisk.co.za

2

Ensure that each section that is relevant to your claim is completed clearly, accurately and completely

3

A copy of the claim form will automatically be sent to medgapclaims@guardrisk.co.za

4

If you are not able to email your claim to us, print your completed claim form and posit it, with all required documents to: The MedGap Claims Team, Guardrisk Insurance Company Limited, PO Box 786015, Sandton, 2146

Update your details
If you need to update any personal information you can complete the relevant section in the online amendment form. You will receive confirmation of the change once updated on our systems.