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Information

Gap cover is designed to protect you from unbudgeted healthcare costs.
Payment shortfalls occur when Medical Aids:

  • pay for treatments at a lower rate than that charged by your doctor
  • impose co-payments for certain procedures or treatments
  • have limits on the amount they pay for certain treatments (sub-limits)

Our gap cover has been designed to protect you from these costs and to boost your medical aid cover. We also provide you with additional benefits and cover when you need it most.

Limits

  • Overall annual limit of R157 000 per insured person per annum (pippa)
  • Cancer co-payment cover limited to 20%, subject to overall limit
  • Sub-limit enhancer limited to R48 500 per event/condition
  • No annual sub-limit for co-payment cover
  • Additional 500% tariff cover
  • Hospital consumables limited to R5 000 pfpa
                    

Acceptance

Unless otherwise approved the following will apply:

  • 3 month general waiting period (not applicable to groups of 20+)
  • 12 month pre-existing condition waiting period

Cover provided for principal member, spouse and children registered on same medical aid

Standard exclusions apply – refer to policy document
Contact us about underwriting waivers for groups

Cover for dependants only applies to your spouse and/or children up to age 26. Other dependants are not covered.

Service Providers

All products are underwritten by Auto & General, an authorised financial services provider (FSP No: 16354). The product is distributed by Hippo Advisory Services, an authorised financial services provider (FSP No: 36088).

Administrator details:
Kaelo Xelus (Pty) Ltd
Registration no: 2008/019335/07 FSP no: 36931
E-mail: info@kaeloxelus.co.za Website: www.kaeloxelus.co.za
Physical address: 2nd Floor, The Oval, East Wing, Wanderers Office
Park, 52 Corlett Drive, Illovo, 2196
Tel: 0861 493 587

MedExpense Gap is not a medical scheme and the cover is not the same as that of a medical scheme. The policy is not a substitute for medical scheme membership. It boosts the cover provided by your medical scheme.

Benefits 2019

Overall Limit R157 000 per insured person per annum (pippa)

IN HOSPITAL
Payment Shortfalls (Tariff)
In hospital specialists - additional 500% - no sub-limit
Blood tests - no sub-limit
Consumables - R5 000 pfpa
MRI/CT/PET scans - additional 500% - no sub-limit
Co-Payments
Rand based pre-admission co-pays - no sub-limit
Penalty co-payments/deductibles - 1 pfpa (max R14 000)
Sub-limit

In-hospital sub-limits increased by R48 500 per event/condition

Hospital Booster Benefit
Paid for trauma and premature birth (more than 6 weeks early) only
Day 1 - 13 R350
Day 14 - 21 R700
Day 22 - 31 R1 400
Maximum benefit of R20 000 pippa
OUT OF HOSPITAL
Payment shortfalls (tariff)
Certain procedures performed in Dr’s Rooms
MRI/CT scans
      
CANCER
Payment Shortfalls (Tariff)
Additional 500% tariff cover
Co-Payments
All % co-payments up to 20% subject to overall limit
If % co-payment does not apply -
100% cover exceeding any annual sub-limits
subject to overall limit
Lump Sum Payout
Positive Diagnosis - R10 000 pb
ADDITIONAL BENEFITS
6 month medical scheme and gap premium waiver on death or
permanent disability of member (R5000pm)

Death or permanent disability cover - accidental - R26 000

600% cover for post trauma reconstructive facial surgery,
surgical correction of birth defects and
intracranial neurosurgery

R13 200 payout for premature birth >42 days early

Dental reconstruction due to oncology
or trauma - R44 000 per event/condition

Accidental casualty ward benefit - R14 000 per event

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