Discovery Gap 500 Plus Pro (Coastal plans)

Discovery Gap 500 Plus Pro is designed for those moments. It covers the shortfalls that sit between what you are charged and what your medical scheme pays, in hospital, in a day clinic, in a casualty unit and, for the first time, in your day-to-day care.

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The Day-to-day Protector helps with the smaller gaps in your everyday healthcare that no gap cover has reached before.

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When you are admitted to hospital or treated in a day clinic, your specialist or healthcare professional may charge more than your medical scheme covers. Discovery Gap 500 Plus Pro pays these fee shortfalls on your approved healthcare professional claims. You are covered for up to 500% of the medical scheme rate, over and above what your medical scheme pays. This applies no matter which Discovery Health Medical Scheme plan you are on.

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This benefit covers tariff shortfalls only. It does not cover other out-of-pocket amounts, such as treatment your scheme excludes or amounts you claim above your scheme's benefit limits.

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Your medical scheme might apply a co-payment or deductible to certain procedures, hospital admissions and surgery. It is a rand amount, and it is shown on the authorisation for your procedure. Discovery Gap 500 Plus Pro covers these amounts when the procedure is done in hospital or in a day clinic, up to your overall annual limit. For co-payments on robotic surgery, you are covered up to R10,000 on your policy each year.

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If you choose a hospital that is not on your medical scheme’s network, your scheme may charge you a fee (called a deductible). It is a rand amount, depending on your plan and scheme rules. Discovery Gap 500 Plus Pro covers this fee up to R17,000 for each claim, for up to two claims per policy each year. We will never pay more than the penalty you were actually charged.

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Your medical scheme sets a limit on certain procedures and items. If you reach one of these limits during an approved hospital admission, Discovery Gap 500 Plus Pro covers the shortfall for the following:

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This benefit applies during an approved hospital admission. If you had already gone past your scheme’s sub-limit before you were admitted, and your scheme paid nothing towards the claim, this benefit does not apply.

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An accident or a sudden illness after hours often means a trip to a casualty unit, and the cost usually comes out of your Medical Savings Account or your own pocket. Discovery Gap 500 Plus Pro covers these visits, up to R18,000 per policy each year. We cover the cost of the casualty visit whether your medical scheme paid it from your Medical Savings Account or you paid it yourself.

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Once you reach your medical scheme’s oncology threshold or limit, Discovery Gap 500 Plus Pro covers your approved cancer-related shortfalls and co-payments, up to your full overall annual Discovery Gap 500 Plus Pro limit.

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If you have a medical emergency while you are travelling outside South Africa, Discovery Gap 500 Plus Pro covers the shortfall on your approved emergency claims.

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We cover the shortfall once your medical scheme’s international travel benefit limit has run out. Your scheme must have paid at least part of the claim. If your scheme’s travel benefit has an upfront deductible on out-of-hospital claims, we cover it, up to $150 or €100. You are covered for one trip on your policy each year, for up to 31 days. If you travel with a dependant, you share the 31 days between you. We cover acute illness and injury while you are travelling for leisure.

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This benefit is available to members under the age of 80. It covers emergencies and unforeseen medical expenses only. It does not cover treatment you planned to have outside South Africa’s borders.

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Discovery Gap 500 Plus Pro rewards you for looking after your health. It works with Personal Health Pathways, which means when you complete certain health actions, you unlock extra cover. The more you do, the more cover you build up.

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Complete all four of these health actions in a year and you unlock R1,000 for each adult on your policy, up to R2,000 for each policy a year:

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The Oncology Protector is a separate policy and it works differently from the other benefits under Discovery Gap 500 Plus Pro. It is a cash payment, not a payment towards a claim. If you’re diagnosed with cancer, a lump sum is paid into your bank account. You don’t need claims from doctors or hospitals, and you won’t have to spend money on medical bills. You can use it for taking time off work, travel to your treatment, childcare or anything else.

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• Any claim your medical scheme excludes. If your scheme will not pay it, we cannot pay it either (such as claims related to weight-loss surgery)
• Any claim where your hospital admission was not approved by your medical scheme and you did not get an authorisation number. Dental specialist claims are an exception, where the admission does not need a hospital authorisation.
• Any claim where the healthcare service or treatment was not provided by an appropriately registered healthcare professional.
• Any claim once you have reached your overall annual limit of R226,881 for the year.
• The cost of an ambulance.
• Claims arising from intentional self-harm.
• During the first twelve months of your policy, any claim for a condition you or a dependant had before your cover started.

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