Stratum Luma300

Gap Cover is a non-life medical expense shortfall policy that complements your medical aid. It is not a medical aid, does not provide the same cover as a medical aid, and cannot replace a medical aid membership. Depending on your policy’s benefits, Gap Cover may help cover certain medical expense shortfalls, co-payments, selected medical aid exclusions, and a range of healthcare-related expenses that can arise before, during, or after a medical event, subject to policy terms, conditions, and benefit limits.

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We pay up to an additional 300% on top of your medical aid plan’s rate to cover shortfalls on your doctors’, specialists’ and healthcare providers’ accounts related to the following in- and out-of-hospital medical events: consumable items, such as catheters, medical gloves and syringes; medication administered during your medical event; medical procedures, surgeries and treatments; physiotherapy; pathology, such as blood, saliva and urine tests; and Prescribed Minimum Benefit (PMB) medical procedures.

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We refund co-payments that your medical aid imposes as rand amounts or percentages for: admissions to network and non-network day clinics and hospitals and medical procedures, such as in- or out-of-hospital scopes and scans, as long as the co-payments are paid from your medical savings account or pocket.

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If your medical aid has a preferred network of day clinics, hospitals and healthcare providers you must use for planned medical procedures, you can claim the penalty co-payments when using non-network providers.

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When co-payments apply to robotic-assisted surgeries, such as prostatectomies, we’ll refund the co-payments.

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We cover the shortfalls when: the cost of your dental-related procedure performed in a day clinic or hospital is more than your medical aid plan’s rate, as long as your medical aid pays an amount from a hospital benefit, also known as a risk or major medical benefit. We refund co-payments that your medical aid imposes as rand amounts or percentages for: admissions to day clinics and hospitals and in-hospital dental-related procedures, as long as the co-payments are paid from your medical savings account or pocket.

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We cover the shortfalls when: healthcare professionals, such as your gynaecologist, obstetrician or midwife, charge more than your medical aid plan’s rate for delivering your baby in the hospital or at home, as long as your medical aid pays an amount from a hospital benefit, also known as a risk or major medical benefit. Subject to our GAP BENEFIT.

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We cover the shortfalls when your healthcare providers charge more than your medical aid plan’s rate for in- or out-of-hospital cancer treatment, as long as your medical aid pays an amount from an oncology benefit.

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If your medical aid plan covers in- or out-of-hospital cancer treatment up to an oncology benefit limit, we’ll top up your cover and pay the total cost of ongoing cancer treatment, up to the available OPL, when your medical aid plan’s oncology benefit limit has been reached.

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We’ll cover the costs and expenses incurred for breast implant reconstruction or flap breast reconstruction surgery that’s not covered by your medical aid plan.

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Claim the shortfalls when: your specialists charge more than your medical aid plan’s rate for virtual or face-to-face consultations in their rooms, as long as your medical aid pays part of the consultation fees from either a risk benefit, also known as an insured day-to-day or block benefit, or from your medical savings account.

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When your medical aid covers the cost of: in- or out-of-hospital MRI, CT, or PET scans from a sub-limit or annual limit, but the rand amount available under the sub-limit or annual limit doesn’t cover the total cost, we’ll cover the difference.

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Visit any registered medical facility within 24 hours of an accident, such as the doctor’s room or emergency unit at the nearest hospital, when anyone in the family requires medical treatment for bodily injury.

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Children 12 years or younger are covered for after-hours illness-related events at any registered casualty facility between 19:00 and 7:00 Monday through Friday and all day Saturday, Sunday, and public holidays.

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We’ll cover the shortfalls when your medical aid pays part of the cost of a casualty event from a risk, insured day-to-day or block benefit, or refund the total cost when paid from your medical savings account or pocket, subject to our benefit limits.

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We’ll cover the shortfalls when your medical aid pays part of your registered counsellor’s consultation fees from a risk, insured day-to-day or block benefit, or refund the total cost when paid from your medical savings account or pocket, subject to our benefit limit.

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Claim the shortfalls when your medical aid pays part of the cost of a private hospital room from a hospital or risk benefit, or the total cost, up to our benefit limit when your medical aid excludes it from cover.

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You’re covered for essential preventative and screening tests. Claim the shortfalls when your medical aid pays part of your healthcare provider’s consultation fee, preventative test or procedure from a risk, insured day-to-day or block benefit, or claim the total cost, up to our benefit limit, when paid from your medical savings account or pocket.

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In the event of accidental death or total and permanent disability due to an accident, a benefit amount is payable on each insured person’s life. Our benefit compensates you for any current or future costs and expenses, including any potential loss of earnings.

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In the event of the medical aid contribution payer’s accidental death or total and permanent disability due to an accident, we’ll step in and pay the monthly contributions. If your employer pays your medical aid contributions on your behalf, the contributions must form part of your total salary package (cost to company).

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In the event of the policy premium payer’s accidental death or total and permanent disability due to an accident, we’ll take over the premium payments. If your employer pays your policy premiums on your behalf, the premiums must form part of your total salary package (cost to company).

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Cover is provided for emergency hospital treatment following an acute illness or accidental injury while travelling for leisure outside South Africa.

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Through our partnership with Reality Wellness Group, you and your dependants have access to confidential counselling with registered counsellors and social workers, telephonically or virtually. Support is available 24/7, 365 days a year, in all 11 official languages.

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Introducing our new option: LUMA300

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• events that occurred before your cover start date, except when claiming from our TRAUMA COUNSELLING BENEFIT.
• events during waiting periods, except for accidental events that occur after your cover start date.
• line items that don’t meet the South African medical coding standards, such as CPT, NHRPL, and ICD-10.
• events your medical aid pays as concessions, exceptions, or ex-gratia payments.
• medical events for which pre-authorisation hasn’t been obtained from your medical aid or when your medical aid’s rules haven’t been followed, except if your policy offers a benefit.
• events when benefit limits or your policy’s overall limit has been reached.
• shortfalls that exceed the 500%, 400% or 300% GAP BENEFIT your policy provides.
• events your policy doesn’t cover or provides an appropriate benefit to claim from.
• additional shortfalls when your healthcare or service provider increases their fees after we’ve finalised your claim.
• additional shortfalls when your healthcare or service provider agrees to a discount but increases their fee after we’ve finalised your claim.
• costs related to medical documents, such as prescriptions, medical reports and the completion of chronic medicine registration forms.
• split billing charges.
• allied healthcare professionals, except if your policy offers a benefit.
• assisted reproductive therapy (ART), fertility treatments or contraceptives, except for contraceptive device implants, tubal ligations, and vasectomies if your policy offers a benefit.
• a second breast reconstruction or any subsequent reconstruction procedure.
• diagnosing or treating sleeping disorders.
• elective, prophylactic (preventative), routine procedures or physical examinations, such as annual check-ups and medical tests for insurance purposes, risk-reducing mastectomies, and scopes based on family history, except if your policy offers a benefit.
• external medical items, such as spectacles, arm slings, compression socks, crutches, moon boots and neck braces, except when claiming from our CASUALTY BENEFIT for items received at the medical facility.
• external prosthetic devices, such as artificial limbs.
• home or private nursing or admission to a step-down or sub-acute facility, such as frail care centres, hospice centres, mental health facilities, and rehabilitation facilities, except if your policy offers a benefit.
• hospital charges, such as ward fees.
• treating mood disorders or emotional or psychological illnesses, except when claiming for counselling from our TRAUMA COUNSELLING BENEFIT.
• obesity or treatments required due to obesity.
• prescription or take-home medication, except when claiming prescription medication from our CANCER BENEFITS.
• reconstructive cosmetic surgery, except if your policy offers a benefit.
• robotic-assisted surgery co-payments, except when claiming from our ROBOTIC SURGERY CO-PAYMENT BENEFIT.
• specialised mechanical or computerised devices, such as CPAP machines, glucometers, insulin pumps, oxygen machines, and ventilators.
• stem cell harvesting or treatments.
• attempted suicide, suicide, or intentional self-injury.
• deliberate exposure to exceptional danger, except if trying to save a human life.
• events covered by legislation, such as contractual liability and consequential loss.
• illegal behaviour or breaking the law of the Republic of South Africa.
• events outside the borders of the Republic of South Africa.
• illness or injury caused by using drugs or narcotics, except if prescribed by a healthcare provider, provided the healthcare provider isn’t an insured person.
• illness or injury caused by using alcohol.
• nuclear weapons, nuclear material or ionising radiation.
• participation in active military, police or police reservist duty, civil commotion, invasion, labour disturbance, political act, rebellion, riot, strike, terrorist activity, war, or the activity of locked-out workers.
• transport charges or healthcare services provided while being transported in an emergency vehicle, vessel, or aircraft.

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