Monthly premium
By age band, as Sirago publishes it. 2027 premiums take effect on 1 January 2027.
| Policyholder’s age | 2026 | 2027 | Change |
|---|---|---|---|
| 0 to 64, just you | R440 | R475 | +8.0% |
| 65 and older, just you | R735 | R795 | +8.2% |
| 0 to 64, family | R505 | R548 | +8.5% |
| 65 and older, family | R820 | R890 | +8.5% |
What it covers
What it pays
Limits and joining
Who is covered
In Sirago’s own words.
- We cover policyholders and dependants of all ages on most options. The benchmark for premium determination is based on whether you join as an individual or as a family and the prospective policyholder’s age at the inception of the policy according to the following two age bands: 64 years or younger; 65 years or older. Sirago Gap Cover Solutions 2027, p5
- The base premium rate includes the policyholder and 4 (four) dependants. (A total of 5 {five} insured persons). All additional dependants added to the policy as listed on the Certificate of Membership (COM) will be charged an additional rate per dependant based on their age as indicated on page 6. Sirago Gap Cover Solutions 2027, p22
- A child is considered a child dependant up to the age of 21. Students: Cover for children can be extended to the age of 27 for full-time students on their own medical aid. Documented proof of full-time study enrolment is required to verify a dependant over the age of 21. On parents’ Medical scheme: Cover can also be provided for children over 21 by submitting the Certificate of Membership (COM) from your Medical scheme confirming that the dependant is still on the same Medical scheme. On own Medical scheme and not students: Children on their own Medical scheme and not a student are required to have their own Gap Cover policy. Sirago Gap Cover Solutions 2027, p5
- You may add your overage dependant to your policy if they are still on your Medical scheme membership, or if they are on their own Medical scheme and are a full-time student. Sirago Gap Cover Solutions 2027, p23
What each benefit means
In Sirago’s own words, with its examples of when it pays and when it doesn’t.
Gap Cover
This covers the difference (the shortfall or the gap) between what the Medical scheme pays and what the doctors and specialists charge in hospital.
You go into the hospital for a knee operation and the orthopedic surgeon charges 5 times the Medical scheme rate. You are on a 100% plan and therefore the shortfall is 400% of the Medical scheme rate. The doctor charges 500% for your procedure; the Medical scheme pays 100% of the 500%; without Gap Cover, you will have to pay the shortfall of 400%.
Sirago Gap Cover Solutions 2027, p8
Co-payments
The Co-payment cover is for the co-payments, excesses, or deductibles as stipulated or imposed by your Medical scheme, for specified procedures, cover for hospital admission fees or surgical procedures. The co-payment must be part of your Medical scheme rules which will be highlighted on the authorisation for your procedure. Refer to the Cancer Co-payment benefit for claims related to cancer.
If you have a back operation and the co-payment or deductible is R15 000, Sirago will reimburse this amount.
Sirago Gap Cover Solutions 2027, p8
Penalty Fee Co-payments
When you choose to use a hospital that is not on your Medical scheme’s network, you may have to pay a stated amount or percentage of the accounts as specified by your Medical scheme rules. Co-payments for administration charges are specifically excluded from cover on this option.
Example 1: You are on Medical Scheme D, and you have a planned procedure at a non-network hospital. The penalty fee is R9 650 which Sirago will reimburse.
Example 2: You are on Medical Scheme M, and you have a planned procedure at a non-network hospital. The Penalty fee is 30% of the hospital bill. Sirago will reimburse up to the benefit amount on the Gap option you are on.
Sirago Gap Cover Solutions 2027, p9
Day Hospital, Clinic, or In-room Surgical Procedures Cover
This benefit will cover the shortfall for any day hospital, clinic, or in-room procedures including acute hospitals if a policyholder elects to have the treatment that would normally be performed in hospital, done in a day hospital, clinic or in a doctor’s room by a registered medical professional. Your cover will be subject to the limits of your chosen Sirago option. Renal Dialysis included in benefit. This benefit will not apply if you go for a routine medical consultation/check-up.
You need a gastroscope, which is normally done in hospital, but your doctor says they can do it in their rooms. We will pay if there is a shortfall on the doctor and anaesthetist.
Sirago Gap Cover Solutions 2027, p9
Prescribed Minimum Benefits (PMB)
The Prescribed Minimum Benefits (PMB) give all scheme members access to certain minimum health benefits, regardless of your Medical scheme option. Medical schemes are required to pay the full cost of diagnosis and treatment of a defined list of PMB medical conditions. PMB Cover on this policy is only for the shortfalls resulting from the voluntary use of a non-designated service provider for a planned PMB procedure. In the event of an emergency, PMB protocols should be adhered to. Your cover will be subject to the limits of your chosen Sirago option.
Example 1: You are rushed to the hospital after a car accident and need emergency surgery. The scheme should pay for all costs in full. Sirago is not responsible for any of the shortfalls.
Example 2: You consult your doctor after experiencing chest pains and he diagnoses a heart condition. He schedules surgery later that week and you request authorisation from the Medical scheme. The Medical scheme stipulates that you need to use a DSP for the planned PMB condition, but your doctor does not work at that facility. The scheme will therefore only pay at scheme rate at a non-DSP and Sirago will cover the shortfall.
Sirago Gap Cover Solutions 2027, p9
Hospital Account Shortfall
This benefit will cover any charges like consumables on the hospital account that the Medical scheme has not paid. We also cover take-home medication (TTOs) that the Medical scheme has not paid from risk and the cost of upgrading to a private ward up to the benefit amount.
Example 1: You are discharged, and the hospital asks you to pay an outstanding amount on the hospital account for things like medication, bandages, oxygen tanks, masks, catheters, and IV bags. Sirago will pay up to the benefit amount.
Example 2: You are discharged and get a script for your take home-medication (TTOs). Only if you collect this from the hospital dispensary, we will reimburse up to the benefit limit whether you have to pay from your pocket or from your available medical savings.
Example 3: You are having a baby and would like to stay in a private ward, Sirago will pay up to the benefit amount for the private room upgrade.
Example 4: You are having a baby and would like a direct family member like your spouse to stay in a private ward with you, Sirago will pay up to the benefit amount for the boarder fee.
Sirago Gap Cover Solutions 2027, p10
Casualty Benefit
This benefit covers the initial emergency at any registered casualty facility when you require immediate medical treatment due to an accident, trauma or illness. We will cover a general practitioner’s (GP) consultation rooms if no other emergency facility is available within a 30 km radius. Ambulance costs are not covered by this benefit. 1. Accident and Trauma: All costs related to the initial accident/trauma event will be covered, whether you are liable to pay the costs out of your pocket or if your Medical scheme pays from your savings. 2. Illness: All costs related to the initial emergency illness event will be covered up to the stated illness benefit, if you are liable to pay the costs related to the emergency event out of your own pocket, or if paid from your Medical scheme savings. This is applicable to any dependant 19 years and older outside of normal consultation hours. 3. Child Casualty Illness: This benefit is applicable to children 18 years and younger, who need emergency illness treatment out of normal consultation hours or treatment that can only be done in an emergency facility. All costs related to the initial event will be covered, whether you are liable to pay the costs out of your own pocket or if your Medical scheme pays from your savings account. Out of normal consultation hours means 18:00 to 07:00 on Monday to Friday, all of Saturday, Sunday and South African public holidays.
Sirago Gap Cover Solutions 2027, p11
Appliance Benefit
This benefit covers the difference between the Medical scheme benefit amount and what the service provider charges, if the Medical scheme option has a defined rand limit, for the following appliances and initial appliance apparatus: hearing aids, wheelchairs, continuous positive airway pressure (CPAP) machines, humidifiers, insulin pumps, glucometers, nebulisers and mirena devices.
Sirago Gap Cover Solutions 2027, p11
Trauma Counselling
This benefit covers trauma counselling with a registered medical professional within the first 12-months after a traumatic event, such as but not limited to dread disease, hijacking and/or violent crime.
Sirago Gap Cover Solutions 2027, p11
Cancer Co-payment Benefit
The Cancer Co-payment benefit is applied once your Medical scheme oncology rand limit benefit has been reached and a percentage co-payment is imposed. This benefit incorporates co-payments for ongoing cancer-related treatments and biological drugs. The ongoing treatment must be in line with the registered treatment plan of your Medical scheme to access this benefit.
You are diagnosed with lung cancer and need to undergo chemotherapy and radiation therapy. Your Medical scheme covers all costs related to the treatment for that specific cancer within their treatment guideline once the overall annual limit has been reached and the scheme imposes a 20% co-payment on all further treatments, we will reimburse the cost related to the co-payment.
Sirago Gap Cover Solutions 2027, p12
Cancer Boost Benefit
The Cancer Boost Benefit is applicable to policyholders whose Medical scheme option has a defined rand limit for cancer treatment and the rand limit on the Medical scheme has been reached. We will cover the costs of ongoing treatment in line with the Medical scheme’s registered treatment plan once the rand limit has been reached.
Sirago Gap Cover Solutions 2027, p12
Gap Cover Premium Waiver
In the event of accidental death or total permanent disability of the Sirago policyholder, we will keep the premiums for your policy as a credit for a period as stipulated for each option. This benefit may be claimed by the surviving spouse or adult dependent on the Sirago policy.
Sirago Gap Cover Solutions 2027, p13
Medical Scheme Contribution Benefit
This benefit will be paid for the upkeep of the Medical Scheme contributions in the event of accidental death or total permanent disability of the Sirago policyholder and where all dependants are linked to a single or dual Medical Scheme membership.
Sirago Gap Cover Solutions 2027, p13
Accidental Death
This benefit will pay out for the accidental death of a dependant.
Sirago Gap Cover Solutions 2027, p13
Initial Cancer Diagnosis (First Diagnosis)
This benefit will pay out a lump sum on the first time you are ever diagnosed with malignant cancer from stage 2 onwards. Any cancer prior to inception of the policy or pre-existing cancer is excluded. Skin cancer is specifically excluded from cover on this policy, except malignant melanomas.
Sirago Gap Cover Solutions 2027, p13
Waiting periods
In Sirago’s own words.
- 3-month general waiting period is applicable on any newly incepted policies and/or additional dependants to the current policy, except in the event of an accident. 10-month waiting period on pre-existing conditions, diseases or illness. Sirago Gap Cover Solutions 2027, p18
- The following conditions are excluded within the first 6-months of the inception of the policy: Myringotomy and grommets; Adenoidectomy; Tonsillectomy; Hysterectomy (except if malignancy is proven); Spinal, back, neck and joint-related procedures (repairs, scopes and joint replacement) except in the case of an accident. This includes treatments related to any and/or investigations such as MRI scans, CT scans, and scopes. Prophylactic mastectomy (only applicable where benefit is available to specific Sirago options). Thereafter, benefits will be payable at a rate of: 50% of benefits will be paid on claims from month 7 to 10. From month 11, the policy benefits will be fully available, unless there are condition specific exclusions. Sirago Gap Cover Solutions 2027, p18
- 3-month waiting period on Initial Cancer Diagnosis. 10-month waiting period for pregnancy and confinement and all related treatment. 12-month waiting period on all pre-existing cancer-related treatments. Sirago Gap Cover Solutions 2027, p18
- All waiting periods are waived if you have held cover for 12-months or longer with your current provider. If you are currently serving waiting periods with your current provider, the balance is applicable with Sirago. If you are transfering to a higher option, a 3-month general waiting period is applied on all additional benefits. Sirago Gap Cover Solutions 2027, p19
- If the Sirago policyholder has held a policy for 12 consecutive months and wants to upgrade to a higher option, all additional benefits will be subject to a 3-month waiting period. If the Sirago policyholder has held a policy for less than 12 consecutive months and wants to upgrade to a higher option, the difference between the balance of the waiting periods imposed will be applied, and a 3-month waiting period on additional benefits. Sirago Gap Cover Solutions 2027, p19
Before you join
Printed on Sirago’s forms.
- Application forms may be underwritten and conditions may be excluded for longer than 10 months. Sirago application form 2027, p2
- The option change is only applicable on 1 January of every year. Sirago application form 2027, p1
- For options: Ultimate Gap, Plus Gap, Gap Assist, Gov Gap, Exact & Exact with Gap and Co-Pay: Dependants are: Spouse and/or dependant children up to the age of 21 years. Students up to the age of 27, if you are on a different medical scheme. Provide proof of enrolment for full time studies or medical scheme certificate. For families who belong to a single medical scheme and option, we cover the policyholder and dependants as listed by the scheme. All additional dependants added to the policy will be charged an additional rate per dependant based on their age as indicated. For further details, please refer to our website. Sirago application form 2027, p1
- Application forms may be underwritten and conditions may be excluded for longer than 10 months. Sirago additional dependants form 2027, p1
- By signing this affidavit, I hereby agree that should any claim be submitted within 90 days of inception of the Sirago Gap Cover policy, that Sirago reserves the right to re-underwrite this policy, backdated to inception of this policy. Sirago affidavit form 2027, p1
- If there’s been a break in cover for 30 days or more between the end date of cover with your current provider, and the cover start date of your new Sirago Benefits Gap Cover Policy, you’ll receive full waiting periods. Pre-existing condition waiting period applicable to like-for-like benefits and/or enhanced benefits: If your current Gap Cover Policy has been active for less than 12 months and a Waiting Period was applied, the balance of the waiting period will be carried over. If our Gap Cover Policy offers enhanced benefits, these benefit categories will have a 3-month General Waiting Period. During the 3-month General Waiting Period, there will be no cover on the enhanced benefit categories. Please submit a copy of your current Policy document - for underwriting purposes this should not be older than 30 days. By completing this form, you acknowledge and accept that your Policy will be subject to waiting periods on your new Sirago Policy Schedule. Sirago replacement confirmation form 2025, p1
How to claim
In Sirago’s own words.
On the website
Navigate to the Sirago website: https://sirago.co.za and select the “Submit a claim” button, which will take you to the claim form. Follow the step-by-step guide on submitting the claim. You will need the following information with you when you submit the claim: Your policy number, this will start with SIR/OMGC/SIRNG; Policyholder’s details. This is the person who holds the policy with Sirago; All claim requirements for the claim submission. (Refer to the “Required documents when claiming - Explanation table” on page 20)
Sirago Gap Cover Solutions 2027, p15
By email
Submit all the claim documents required to claims@sirago.co.za. Remember to include the following information in the submission: Your policy number, this will start with SIR/OMGC/SIRNG; The claim form needs to be fully completed and signed by the policyholder of the Sirago policy (Including disclaimers); All claim requirements for the claim submission. (Refer to the required documents list below.)
Sirago Gap Cover Solutions 2027, p15
Through your broker
Once you have accessed the specific policy, look for the applicable dependant and select Actions>Register Claim. Register your claim. (Use the link as a guide for registering a claim: https://support.sirago.co.za/support/solutions/articles/77000510865-submitting-a-claim-on-the-broker-portal). Once registered you can select the “view summary” button to access the claim to get the claim number. This will be required to submit the supporting documents. Upload supporting documents, including the claim form.
Sirago Gap Cover Solutions 2027, p15
When to send it
We must receive your claim with all supporting documentation within 180 days from date of admission.
Sirago Gap Cover Solutions 2027, p15
Documents to send
Sirago Gap Cover claim form completed and signed by the Policyholder; all approved claims will be paid into the bank account details registered with Sirago, unless alternative bank details are provided on the claim form. If the claim is related to a hospital admission, a detailed hospital account is always required. Your Medical scheme statement showing all the payments made by you or your Medical scheme for the health event. Completed medical reports substantiating the clinical information or any other documentation if requested by our claims team. Pre-authorisation letter from your Medical scheme for co-payment claims. Gap and Medical Scheme Premium Waiver claims: Accidental death certificate, SAPS accident report and/or a total permanent disablement certificate or reports from a registered medical practitioner. Value Added Benefit claims: A monthly Certificate of Membership from the Medical scheme is required for Medical Scheme Premium Waiver benefit, this needs to include the month and the monthly premium. Initial Cancer Diagnosis: Confirmation from the treating provider, the stage of cancer initially diagnosed with, including the histology report.
Sirago Gap Cover Solutions 2027, p15
What each document is for
| Document | Where to get it | Why Sirago needs it | Note |
|---|---|---|---|
| Sirago Claim Form | You can obtain this from our website: www.sirago.co.za/download/. You can contact one of our friendly customer experience centre consultants on 010 599 1163. You can WhatsApp one of our friendly customer extperience centre consultants on 076 562 1340. | Verify the correct policy to register a claim. Allows us to update information. Validates account details for claim payments once assessed. | This document needs to be completed and signed by the Sirago policyholder. All disclaimers and information needs to be completed to process the claim. |
| A detailed Hospital account | This is obtained from the hospital where you were admitted, whether it be one day admission or a lengthy stay in hospital. | The length of stay in hospital and the specific provider or practice details. Patient details. ICD-10 (Diagnosis) Code. Detail and summary of the costs for the hospital stay. The discounts applied by the hospital, where applicable. | A summary Hospital account will regrettably not suffice. |
| Service provider’s invoice / Doctor’s invoice | This is obtained from the treating provider’s accounts department who performed the procedure. | The provider’s name, practice number and type of provider seen. Patient’s details. Date which the patient saw the provider. ICD-10 (Diagnosis) Code the patient was treated for. | The amounts charged on this account need to correspond with the charged amounts on the Medical scheme statement. |
| Completed medical reports | This can be obtained from the doctor whom first diagnosed/treated you for symptoms. | Date of awareness of symptoms. When the provider was first seen. The history of the condition. | |
| Confirmation of pre-authorisation | You can obtain this from your Medical scheme. | Date of expected admission. The patient details. The hospital and length of stay. The benefit the scheme has on the client’s specific options; this includes: Benefit limits or sub-limits on specific benefits; The deductibles/co-payments that the client is liable for; The reason for the Scheme imposed co-payment. | |
| Facility Account (Step down benefits) | This is obtained from the accounts department from the facility the patient was admitted in as a step-down facility. | The length of stay at the specific facility the patient was admitted to. The patient’s details. The ICD-10 (Diagnosis) Code. The details and summary of the costs for the stay at the step-down facility. Discounts applied by the facility, where applicable. | |
| Casualty facility Invoice (Casualty Benefits) | This is obtained from the accounts department from the Casualty facility you visited. | Date and time the patient was admitted to the emergency facility. Patient details. ICD-10 (Diagnosis) Code. Detail and summary of the costs for the casualty visit. Discounts applied by the hospital, where applicable. | |
| Confirmation of oncology registration programme | This can be obtained from your Medical scheme. | Cancer treatment approved by the Medical scheme. The frequency of the specific treatment for each specific provider/doctor. | |
| Death certificate | This can be obtained from Home Affairs. | The identity of the demised person. The date of the demise. The category of cause of death. | |
| Fully completed DHA1663 Form / BI-1663 Form | This is provided by the medical practitioner/forensic pathologist. | This document provides particulars of the demise of the person, which assists us in the assessing of the claim under specific benefit of entitlements. | |
| SAPS accident report | SAPS that you reported the accidental death to. | This provides us with specific information to validate your claim against the benefits on your chosen option. | |
| Medical Scheme membership certificate | This can be obtained from your Medical scheme, monthly. | Monthly active membership. Monthly contribution on the active membership. | |
| Completed debit order authority form (if applicable) for the death of the policyholder | You can obtain this from our website: https://www.sirago.co.za/downloads-copy/. You can contact one of our friendly customer experience centre consultants on 010 599 1163. You can WhatsApp one of our friendly customer experience centre consultants on 076 562 1340. | The policyholder’s details. New debit order account details. |
Sirago Gap Cover Solutions 2027, p16-17
Claims Sirago paid in 2026
Examples Sirago publishes.
| Claim | Doctor charged | Medical scheme paid | Sirago paid | Member paid |
|---|---|---|---|---|
| Carcinoma – Oral activity & Pharynx | R260 965.92 | R40 222.84 | R189 437.70 | R0.00 |
| Maternal Care | R78 300.00 | R18 385.87 | R59 914.13 | R0.00 |
| Obstetrics | R30 473.57 | R7 576.30 | R22 895.30 | R0.00 |
| Circuatory System | R30 584.90 | R11 637.94 | R18 946.96 | R0.00 |
Sirago Gap Cover Solutions 2027, p4
What it does not pay for
Sirago’s exclusions (58)
- Benefits that your Medical scheme excludes or does not pay for, or has not paid a portion of the claim, or if you have used up your whole benefit limit on the Medical scheme, unless otherwise specified.
- If there is no authorisation from the Medical scheme and they do not pay, neither does Sirago.
- The first 100% of the Medical scheme tariff or rate for any claim. Medical scheme should be responsible for the first 100% or 200% of the claim, according to your Medical scheme option.
- Claims that exceed the limit of each benefit category.
- Out-patient or day-to-day treatment, consultations, investigations, or surgical procedures unless there is a specific benefit on your Sirago option.
- Any experimental treatments and medication, both in and out of hospital, unless it forms part of your benefit entitlement.
- Any claim less than a minimum amount of R100 due to the client per provider.
- Claims for organ donations and recipients do not have any benefit entitlement.
- In the event that there were no benefits available from the scheme at the time of the procedure, Sirago will not provide any benefits in this regard.
- There will be no benefit for claims related to or resulting from the natural causes of death of the policyholder under the Gap and Medical Scheme premium waiver benefits, where benefit is applicable on your chosen option.
- There will be no benefit for claims related to or resulting from the initial diagnosis of cancer from stage 0-1; there is only benefit for initial diagnosis of malignant cancer from stage 2 onwards, where benefit is applicable on your chosen option.
- There will be no benefit for the initial diagnosis for skin cancer.
- There will be no benefit in the event of natural death of the policyholder under the Gap and Medical scheme contribution benefit, where benefit is applicable on your chosen option.
- There is no valid gap shortfall to assess, as your Medical scheme has settled the claim in full.
- Casualty Illness benefit that falls within normal consultation hours.
- Casualty Illness or Child Casualty Illness benefit where there is no benefit entitlement included on your chosen Gap option.
- Medication, drugs, prescriptions, consumables, and equipment used, unless it forms part of the benefits of this policy.
- Devices, such as artificial joints, braces, crutches, dental implants, crowns, orthodontic, prosthodontic and all cosmetic dentistry including all forms of internal and external prosthesis as defined, unless specified as part of the benefit entitlement of this policy.
- Discounts negotiated by the insured person directly with a service provider where re-imbursement of a claim will/could enrich the insured person.
- Any other related charges and costs incurred during the specialist and primary care consultation fee benefit performed during the visit will not be covered, unless defined as part of the benefit entitlement included in your chosen Gap option.
- Any costs related to out-of-hospital radiology and pathology are excluded from cover, unless defined as part of the benefit entitlement of your chosen Gap option.
- Any costs related to emergency Prescribed Minimum Benefit (PMB) costs/medical interventions, unless defined as part of the benefit entitlement of your chosen Gap option.
- Any follow-up visits to casualty/treating providers will not be covered, unless specifically covered under the benefit entitlement of your chosen option.
- An event not covered by this policy and/or falling outside of the policy’s intention.
- An event where pre-authorisation was not obtained from the Medical scheme or where Medical scheme rules were not adhered to.
- Any claim that must be paid in terms of alternate proclaimed legislation, such as the Compensation for Occupational Injuries Act 90 of 1993, and the Road Accident Fund Act 56 of 1996.
- Any dependant not registered on the policy at the time of the event.
- Any pre-existing condition, disease, disorder, or illness, for the first 10-months. This will include any condition which existed before inception, whether diagnosed or not, or for which an insured person has sought or received medical advice, received treatment by a registered medical professional, or exhibited symptoms, before the actual inception of the policy.
- Any pre-existing cancer condition, disease, disorder, or illness, for the first 12-months. This will include any condition which existed before inception, whether diagnosed or not, or for which an insured person has sought or received medical advice, received treatment by a registered medical professional or exhibited symptoms before the actual inception of the policy.
- Breast reconstruction and breast reconstruction performed as a secondary or subsequent reconstruction, unless part of the benefit entitlement of your Sirago option.
- Intraocular lenses, unless part of the benefit entitlement of your Sirago option.
- Claims for regular or routine medical treatment or advice on an on-going basis and routine physical examinations or procedures purely of a diagnostic nature, unless part of the benefit entitlement of your Sirago option.
- Any illness, injury, or consequence of alcohol, drug or substance intoxication, use, abuse, or addiction, whether directly or indirectly traceable to the insured being affected permanently or temporarily.
- Any psychiatric, psychological, emotional or nervous condition/s including, but not limited to, depression, insanity, psychosis, stress-related disorders, affective disorders, anxiety disorders, psychiatric conditions, and any other mental or behavioural disorders classified under ICD-10 codes F01-F99, mental, behavioural & neurodevelopmental disorders, unless specifically defined as part of the benefit entitlement of your chosen Gap option.
- Suicide, attempted suicide, or any intentional or deliberate self-injury and/or self-exposure to danger or risk except to save a human life.
- Cosmetic surgery where there is no clinical indication for treatment, including any treatment and costs resulting from these procedures, unless specified as part of the option benefit entitlement.
- Elective procedures that have no clinical or medical indication, including any treatment and costs resulting from these procedures, unless specified as part of the benefit entitlement.
- Investigations, treatment, or surgery for eating disorders, obesity, or weight management, including any consequence of such treatment.
- Investigations, treatment, medication, or surgery related to any condition where the policyholder seeks advice, diagnosis and/or treatments outside the border of South Africa.
- Investigations, treatment, or surgery related to infertility, artificial insemination, hormone treatment for infertility, or any other form of assisted reproduction.
- Any claim related to contraceptive device implantation, unless specified in option’s benefit entitlement.
- Robotic surgery which includes specialised mechanical or computerised appliances and equipment, unless specified as part of the benefit entitlement of your chosen Gap option.
- Any claim submitted where you and/or your dependant has previously been diagnosed with cancer in your lifetime will not qualify for the initial cancer diagnosis benefit.
- An event approved by the scheme outside of the normal scheme rules by Ex-Gratia will not be covered on this policy.
- An event resulting in or related to gender reassignment or gender reassignment reversal procedures, treatment or admission does not fall within the benefit entitlement.
- Any claim related to nuclear medicine.
- Participation in any form of race or speed test, other than on foot.
- Sports involving any mechanically propelled vehicles or crafts.
- Participation in a sport that is defined as hazardous or dangerous, except for scholars taking part in school activities.
- Any claim arising directly or indirectly from active involvement in war, invasion, an act of a foreign enemy, hostilities (whether war be declared or not), civil war, rebellion, revolution, insurrection or political risk of any kind, or any act of any person acting on behalf of or in connection with any organisation, group or activity aimed at overthrowing any government by force or any deliberate act of terrorism or violence.
- Any riot, strike, or public disorder (including civil commotion, labour disturbances or lock-out) or any act or activity resulting in, or calculated to bring about a riot, strike, or such disorder.
- Active military duty, police duty, police reservist duty, civil commotion, labour disturbances, riot, strike, or the activities of locked-out workers.
- The act of any lawfully established authority, police force, security force, or any other local, provincial, or national body, in controlling, preventing, suppressing or in any other way dealing with any event referred to in the clauses above.
- Compensation in terms of the War Damage Insurance Act 85 of 1976.
- Nuclear weapons or nuclear material, ionizing radiation, or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel. For this exception combustion shall include any self-sustaining process of nuclear fission.
- Any loss arising from any contractual liability.
- Any consequential loss or damage whatsoever.
- Any attempt by you to commit an unlawful act.
Sirago Gap Cover Solutions 2027, p20
Words used
As Sirago defines them.
- Waiting period
- A “waiting period” is a defined period of time in which a policyholder may not claim any, or may only claim certain policy benefits. Sirago Gap Cover Solutions 2027, p18
- Overall Annual Limit (OAL)
- The Overall Annual Limit (OAL) of R232 000 per dependant per annum. Each benefit category adds up to the OAL, with certain benefit categories having sub-limits applicable within the OAL. All benefit categories are per policy, per annum. Sirago Gap Cover Solutions 2027, p8
- Individual Membership
- The premium for an individual will apply if there is one policyholder and no dependants on the policy. Sirago Gap Cover Solutions 2027, p5
- Family Membership
- This policy will cover the policyholder and the dependants who are listed on the Schedule of Insurance. Sirago Gap Cover Solutions 2027, p5
- Single Medical Scheme Membership
- We cover all members listed on the Medical Scheme Certificate of Membership (COM). Sirago Gap Cover Solutions 2027, p5
- Dual (two) Medical Scheme Membership
- Dual Medical scheme membership is when the policyholder and dependants belong to more than 1 (one) Medical scheme membership. Cover is limited to a maximum of 2 (two) adults and all the child dependants on 1 (one) policy if you belong to a dual Medical Scheme. We cover all members listed on both the certificates of membership (COM). Sirago Gap Cover Solutions 2027, p5
- Large loss claim
- A large loss claim is a claim where the shortfall is equivalent or greater than R85 000. These claims are to be signed off by the Insurer and sent for negotiation by a third-party provider who will assist in contacting the healthcare provider directly to get a discount on your behalf. Sirago Gap Cover Solutions 2027, p22
- Repudiation / falls out of the policy intention
- This means there is no cover available on your policy for the claimed event, according to your benefit entitlement. Sirago Gap Cover Solutions 2027, p22
- Split billing
- Should your gynaecologist request you to pay an upfront co-payment, this does not form part of the amount for a specific procedure code - this is called split billing. Therefore, this would fall under our policy specific exclusions as it does not fall within our co-payment benefits or any of the other benefits on the Sirago products. Sirago Gap Cover Solutions 2027, p22
- Accidental Death
- Death caused by an external, violent, unexpected and visible event. The accidental death benefit does not provide cover for suicide or death by natural causes. The death certificate must say “unnatural death”. We do not pay for natural death. For example, we will not pay if death is caused by an illness. We will however pay if the death was caused by a car accident and it is stated as an unnatural death on the death certificate and SAPS accident report. Sirago Gap Cover Solutions 2027, p23
- Exact Cover
- The Exact Cover option provides access to a defined list of stated procedures when your Medical scheme option excludes those specific procedures over and above their standard exclusions. Sirago will negotiate with all service providers on your behalf and pay the claim directly, up to the stated amounts as listed below. The cost of the hospital and all service providers are included in the cover limit. To access the exact cover benefits, policyholders are required to preauthorise the event with Sirago prior to incurring any expenses and admissions to hospital. Failure to do so will render the claim repudiated. Sirago Exact brochure 2027, p1
- Exact with Gap and Co-Pay Cover
- The Exact with Gap and Co-Pay option provides cover for specific procedures that your Medical scheme excludes, with additional Gap and Co-payment cover for the events that are covered by the Medical scheme. Sirago Exact with Gap and CoPay brochure 2027, p1
- ICD Augmentation (Initial Cancer Diagnosis Augmentation Cover)
- This optional add-on will payout a lump sum once your embedded initial cancer diagnosis benefit on your existing Sirago policy has paid out upon the initial diagnosis of malignant cancer from stage 2 onwards. Should your existing Sirago policy not provide cover for initial cancer diagnosis from Stage 2 onwards, claim requirements will be required to validate the claim. This benefit will be paid out as per occurrence on your option, 1, 2, 3 or 4 months after the initial embedded benefit or upon approval of initial cancer diagnosis. {Stage 2 onwards} Sirago ICD Augmentation brochure 2027, p1
Questions about Gap Assist
Answered from Sirago’s brochures.
How much does Gap Assist cost in 2027?
From 1 January 2027: R475 a month for one person, R548 for a family (policyholder aged 0 to 64); R795 a month for one person, R890 for a family (policyholder aged 65 and older).
How much is Gap Assist going up for 2027?
For a family at 0 to 64, from R505 to R548 a month, +8.5%.
Is there a waiting period?
Yes. 3 months general, and 10 months for conditions you had before joining.
Does Gap Assist cover cancer?
Yes, Gap Assist includes cancer cover.
Which co-payments does it cover?
One co-payment a year that your medical scheme charges.
Is there a limit on what it pays?
Yes. R232 000 per person a year from 1 April 2027, and R223 000 before that.
Sirago’s own answers
Quoted from Sirago’s frequently asked questions (Sirago Gap Cover Solutions 2027, pp22–23).
Can I have Gap cover without Medical scheme cover?
No, Gap cover is a non-life insurance product which compliments your Medical scheme benefits. It is not the same as a medical scheme and cannot take the place of a Medical scheme. To qualify for Gap cover you need to have active membership with a registered Medical scheme in South Africa.
How do I add a dependant onto my policy?
Simply complete and submit the additional dependant form to applications@sirago.co.za
Will Sirago cover costs for procedures done overseas?
Gap cover only provides benefit for treatment provided within the borders of South Africa.
Can I get pre-authorisation from my Gap cover for my operation?
No, pre-authorisation may not be provided as we are not a Medical scheme. This is not a Medical scheme and the cover is not the same as that of a Medical scheme. This policy is not a substitute for Medical scheme membership. Once a procedure has been performed, all claim requirements need to be submitted for us to assess the claims against the product benefits.
Will Sirago pay my doctor directly?
Providers cannot be the nominated account for claims to be paid. If a discount is negotiated on your behalf by our third-party provider, then we will make payment directly into the healthcare provider’s account within 24 hours.
What is the maximum family members covered on Gap?
Individual membership: The premium for an individual will apply if there is one policyholder and no dependants on the policy. Family membership: This policy will cover the policyholder and the dependants who are listed on the Schedule of Insurance. The base premium rate includes the policyholder and 4 (four) dependants. (A total of 5 {five} insured persons). Single Medical Scheme Membership: We cover all members listed on the Certificate of Membership (COM). Dual Medical Scheme membership: Dual Medical scheme membership is when the policyholder and dependants belong to more than one Medical scheme membership. Cover is limit to a maximum of 2 (two) adults and all the child dependants on 1 (one) policy if you belong to a dual Medical scheme. We cover all members listed on the Medical Scheme Certificate (COM). All additional dependants added to the policy as listed on the Certificate of Membership (COM) will be charged an additional rate per dependant based on their age as indicated on page 6.
My debit order has returned as unpaid. How can I pay my premiums, and to which account can I make a payment?
Once your premium is returned as unpaid and you have received the communication, please follow the Pay@ link to make payment.
What are the claim requirements to submit a claim?
Please navigate to page 15 or visit the Sirago website and click on the tab “Requirements for submitting a claim”. Website link: www.sirago.co.za
Where do I submit my claim?
You can either submit your claim via our online claim submission portal: https://siragoregisterclaim.azurewebsites.net or you may submit your claim via email to claims@sirago.co.za
How long will it take Gap cover to pay my claim?
The turnaround time is 10 working days, provided that all required documents are received.
What is the minimum amount that I can claim for?
The minimum amount that you can claim for on any Sirago policy is R100 per provider.
Please explain Sirago repudiations or “falls out of the policy intention”.
This means there is no cover available on your policy for the claimed event, according to your benefit entitlement.
What is a large loss claim?
A large loss claim is a claim where the shortfall is equivalent or greater than R85 000. These claims are to be signed off by the Insurer and sent for negotiation by a third-party provider who will assist in contacting the healthcare provider directly to get a discount on your behalf.
Will you cover claims for my pregnancy?
All pregnancy and confinement claims are excluded for 10-months from the inception of the policy. Once this waiting period has lapsed, we will provide benefit for the Gap component of the in-hospital procedure and for the specialist consultation fee up to your benefit limit. Furthermore, we have a Sira’Go baby benefit that provides cover for the stated benefit amount per newborn when they are added onto the Sirago policy within 90 days of birth. Maternity cover is provided as follows: Tariff Shortfall Benefit: As per the policy benefit for in-hospital procedures. Admission & Procedure Co-Pays: As per the scheme. Penalty Fee Co-Pays: As per your policy benefit. Specialist Consultation Fee Benefit: Provided there has been a positive payment by the scheme as per the agreed scheme rate for the consultation. Preventative Care Benefit: As outlined in your policy wording. Private Room Benefit: As outlined in your policy wording.
Will my newborn baby be covered from birth if I have a waiting period for pregnancy and confinement?
Should your baby be born onto the policy, Sirago will cover the baby’s treatment or procedures. We also have a Value-Added Benefit called Sira’Go Baby. You will need to submit your baby’s birth certificate to us within 90 days from birth to register your baby on the policy.
If I get a discount on my doctor’s account, will Sirago cover me for the discounted amount I received?
No, since the discount amount that we have negotiated with the doctor will be written off and is not due for payment by you.
Will Gap cover pay for a co-payment that my Gynaecologist told me to pay before my child’s birth?
There is a benefit for specific co-payments imposed by your Medical scheme, outlined in the policy wording. Should your gynaecologist request you to pay an upfront co-payment, this does not form part of the amount for a specific procedure code - this is called split billing. Therefore, this would fall under our policy specific exclusions as it does not fall within our co-payment benefits or any of the other benefits on the Sirago products.
Will Gap cover pay for everything that my Medical scheme does not pay?
In short, no. The Gap cover benefit provides cover for the difference between the registered healthcare professional’s tariffs and the scheme’s payment (first 100% scheme rate); therefore, we will not cover any procedure or treatment not covered by your Medical scheme, unless specified as part of your benefit entitlement. This is not a Medical scheme, and the cover is not the same as that of a Medical scheme. This policy is not a substitute for Medical scheme membership.
Will Sirago contact my Medical scheme and doctor for the outstanding documents?
Regrettably, we are not authorised to contact your Medical scheme or provider for any outstanding documents. Your healthcare provider will not provide us with the outstanding documentation as we are not a registered Financial Advisor/policyholder/patient.
Why does Sirago require provider accounts and hospital accounts?
To review a claim, we require the final accounts and Medical scheme statements to validate the claim against the policy benefits. The provider and hospital accounts provide us with information and details of the procedure performed.
If my Medical scheme pays the only amount left in my savings towards my GP account, will Gap cover pay the rest of the shortfall?
If there is benefit on your chosen Sirago option and the scheme has paid an amount towards the consultation fee, we will process the difference between your registered healthcare provider’s charged amount and the Medical scheme rate. We will pay according to your Medical scheme option: Hospital Plan: Benefits will be paid if your Medical scheme pays a portion of the claim. Savings Plan: Benefits will be paid if your Medical scheme pays a portion of the claim. However, the value settled by the Insurer will be limited to the Gap portion, after the scheme has defrayed the scheme rate of the claim if there was an accumulated or allocated savings balance at the time of claim. Traditional Medical scheme option: Benefits will be paid if your Medical scheme pays a portion of the claim.
What happens if my savings are depleted? Will I still be able to claim the co-payment?
Yes, you can claim for a co-payment if your savings are depleted as long as this is for a procedural co-payment and falls within your chosen Gap option’s benefit entitlement.
Can I claim for day-to-day benefits if my savings are depleted?
No, you are unable to claim for any day-to-day benefits when savings are depleted.
When the appliance is funded from savings, can I claim the difference for my appliance benefit?
The Medical scheme needs to provide a defined rand value towards the appliance and there needs to be a payment from the Medical scheme.
The Casualty benefit – can I claim if the Medical scheme has paid it from my savings?
Yes, you can claim if the Casualty benefit has been paid from your Medical scheme savings or out of pocket.
Are there benefits for GP visits?
The Primary Care benefit provides cover for the Gap component of GPs, outlined alternative providers and dental consultations for specific options.
Does Sirago cover dentistry?
Regrettably, basic dentistry is excluded on all Sirago options, this includes but is not limited to crowns. Dental procedures like wisdom teeth removal in and out-of-hospital is covered under the Day Clinic/In room procedure benefit. Depending on your chosen Sirago option, you may however qualify for the Gap component of the dentist consultation fee, provided that your Medical scheme has paid their scheme rate (First 100%) and your chosen Sirago option provides cover for Primary Care Consultations.
Will Sirago cover my orthodontic treatment?
Regrettably, orthodontic treatment is not covered on the Sirago options.
Will Sirago cover my dietician’s consultation?
Regrettably, there is no benefit for dieticians.
Has Sirago got a psychiatric benefit for stress and mental illnesses?
Regrettably, any psychiatric or psychological condition, or emotional or nervous conditions and treatment is excluded on Gap cover. This includes but is not limited to depression, insanity, psychosis, stress-related and addictive disorders. Suicide, attempted suicide or any intention or deliberate self-injury/self-exposure to danger or risk except to save a human life is also excluded.
My policy incepted on 01/01/2026 and I was diagnosed with cancer on 31/12/2025. Can I claim for the Initial Cancer Diagnosis (First Diagnosis) benefit?
Regrettably, you will not qualify for the benefit as the diagnosis was prior to the inception of your policy and will be noted as a pre-existing condition, which will be excluded for 12-months from inception. Should you be diagnosed after the inception of your policy, a 3-month general waiting period will apply, specifically for initial diagnoses of cancer. Therefore, if you are diagnosed within those 3-months, you will not qualify for the benefit.
Will my blood test and x-rays be covered if it is done Out-of-Hospital?
There is regrettably no cover for Out-of-Hospital shortfalls for blood tests and x-rays.
Can I claim from the Preventative Care benefit if there was no payment by the scheme?
You are able to claim up to R1 000 towards tests/procedures listed, provided there was no benefit available at the time of the test.
Can I claim against the Sira’Go Baby benefit if I register my newborn on my Medical Scheme only?
No, you cannot claim the benefit as the benefit is paid out once the child is registered on your Sirago Gap policy.
Can I claim if my savings are depleted and I pay for a specialist consultation out of pocket?
We only pay for the shortfall on the specialist consultation fee when your Medical scheme pays the Medical scheme agreed rate for the consultation and your chosen Sirago gap cover option provides this benefit.
When completing a claim form, should the name be used of the patient who is a dependant on the policy or the name of the policyholder?
Claim forms must always be completed in the name of the Policyholder.
Is the OAL of R232 000 per dependant or per policy?
The OAL is R232 000 per dependant per annum from 1 April 2027.
Can I add my overage dependant (child over 21) to my gap cover.
You may add your overage dependant to your policy if they are still on your Medical scheme membership, or if they are on their own Medical scheme and are a full-time student.
Define Accidental Death.
Death caused by an external, violent, unexpected and visible event. The accidental death benefit does not provide cover for suicide or death by natural causes. The death certificate must say “unnatural death”. We do not pay for natural death. For example, we will not pay if death is caused by an illness. We will however pay if the death was caused by a car accident and it is stated as an unnatural death on the death certificate and SAPS accident report.
Factual information from Sirago’s published brochures. It is not advice. Compiled by Eldon de Waal, CFA, the licensed advisor behind AURA. Catalogue v175, built 2026-10-19.