Gap Cover insurance Questions & Answers

What is gap cover? Why is it important to have Gap Cover insurance? Can a person apply for gap cover without being a registered member of a medical scheme? Is a gap cover policy valid when a client changes from one medical scheme to another? Does the product cover the same family members that are registered on the medical scheme? May a principal member and his/her spouse belong to separate medical schemes but have one gap policy? When is a gap cover policy active? Can a gap cover policy be reinstated? When will a gap cover policy automatically be cancelled? What is the notice period for cancelling the gap cover policy? Which debit order dates are available? What happens if the 1st, 15th, 20th, 25th or the 28th fall on a weekend or public holiday? Will the gap cover premium be debited together with the medical scheme contribution? Will new waiting periods be imposed when changing from one medical scheme to another ? Is a newborn baby covered under the gap cover policy? Is a new spouse covered under the gap cover policy? Does underwriting apply to newborn babies and new spouses if registered within 30 days? Are students covered? What are the policy exclusions and waiting periods? What is the time frame in which a client can submit a gap claim? What documentation must be submitted when claiming? What is a remittance advice? May a member upgrade to a private hospital ward and claim the difference from gap cover? Should a client claim immediately from Stratum Benefits after hospitalisation? Are claims covered for medical services rendered outside the borders of South Africa? What amount is payable to the client once a claim has been submitted? Can a client claim whilst the policy is suspended? Can a client claim if the policy has lapsed? What is the turnaround time for processing new business applications? When and how do clients receive their policy documents? What is the turnaround time for queries? What is the turnaround time for processing of claims? How do you claim?

What is gap cover?

It is a short term product that covers the difference between doctors' and specialists' fees for in-hospital events and the rate at which medical schemes reimburse them at.

Why is it important to have Gap Cover insurance?

Due to the ever increasing medical expenses and the inability of medical schemes to cover all these expenses, gap cover is a necessity as it can assist medical scheme expenses that might be incurred when hospitalised.

Can a person apply for gap cover without being a registered member of a medical scheme?

No, gap products only work in conjunction with registered South African medical schemes.

Is a gap cover policy valid when a client changes from one medical scheme to another?

Yes, as long as they remain an active member of a registered medical scheme.

Does the product cover the same family members that are registered on the medical scheme?

Gap cover will cover a family comprising of a principal member, a spouse and child dependants. Adult dependants that might be registered on the medical scheme, will have to take out their own gap policy.

May a principal member and his/her spouse belong to separate medical schemes but have one gap policy?

Yes, it is not necessary to apply for different gap cover options. Spouses can enjoy family cover on one product. However proof of both schemes are required when applying.

When is a gap cover policy active?

After the first monthly premium has been received.

Can a gap cover policy be reinstated?

No, once the policy has lapsed the client would need to reapply and new waiting periods will be imposed.

When will a gap cover policy automatically be cancelled?

On the return of a double debit as the policy will then be two months in arrears.

What is the notice period for cancelling the gap cover policy?

One calendar month's written notice is required.

Which debit order dates are available?

The 1st, 15th, 20th, 25th or the 28th of every month.

What happens if the 1st, 15th, 20th, 25th or the 28th fall on a weekend or public holiday?

A debit will be taken on the first available working day.

Will the gap cover premium be debited together with the medical scheme contribution?

No, gap cover is separate insurance from medical scheme cover.

Will new waiting periods be imposed when changing from one medical scheme to another ?

No. Although the gap cover policy runs in conjunction with medical scheme cover, gap cover waiting periods will not be affected in this instance.

Is a newborn baby covered under the gap cover policy?

Yes, provided the baby is registered within 30 days from date of birth and provided that the policy is older than 3 months.

Is a new spouse covered under the gap cover policy?

Yes, provided the spouse is registered within 30 days from date of marriage and provided that the policy is older than 3 months.

Does underwriting apply to newborn babies and new spouses if registered within 30 days?

No, a general 3 month and a 12 month pre-existing waiting period will not be imposed, however policy exclusions and waiting periods will apply.

Are students covered?

Yes, children up to the age of 21 and students up to the age of 26. Proof of student membership is required annually once a child reaches the age of 21.

What are the policy exclusions and waiting periods?

Please refer to the product policy document for a list of the exclusions and waiting periods as there are specific waiting periods applicable to the different gap cover options.

What is the time frame in which a client can submit a gap claim?

Within 6 months from the date of hospital admission.

What documentation must be submitted when claiming?

  A fully completed Stratum Benefits claim form, the medical scheme claims transaction history pertaining to the hospital admission, invoices, doctors accounts or statements and your medical aid membership certificate.

What is a remittance advice?

A remittance advice is a statement (claims transaction history) from your medical scheme reflecting the history of your claims pertaining to your hospital admission.

May a member upgrade to a private hospital ward and claim the difference from gap cover?

Unfortunately not as ward fees are not covered under gap cover

Should a client claim immediately from Stratum Benefits after hospitalisation?

The claimant may either wait to be refunded by Stratum Benefits as claims are paid out once per month or the client can pay the doctors directly and then claim back from Stratum Benefits.

Are claims covered for medical services rendered outside the borders of South Africa?

No, cover is only provided within our borders.

What amount is payable to the client once a claim has been submitted?

This depends on the actual claim and the shortfall amount.

Can a client claim whilst the policy is suspended?

Yes, but the claim will only be assessed after the arrear premium has been paid.

Can a client claim if the policy has lapsed?

No, once the policy has lapsed the client will not be eligible for any benefits.

What is the turnaround time for processing new business applications?

If the application form is clear, banking details are correct and a copy of I.D. and medical scheme membership certificate is provided – 48 working hours.

When and how do clients receive their policy documents?

Once a new application form has successfully been captured, the client will receive a policy document via email.

What is the turnaround time for queries?

If sent to the correct person in the correct department – 48 working hours.

What is the turnaround time for processing of claims?

If a claim is submitted within the first year of membership it is subject to underwriting and if submitted after the first year, it will take a maximum of 7 days for feedback to be given.

How do you claim?

As this policy does not form part of your medical scheme you will need to submit a separate claim to the Gap Cover provider Your completed claim form must be submitted with the following documentation:   - Hospital account/s - Doctor, surgeon, specialist and anaesthetist account/s - Receipt in the event that you have paid a co-payment/deductible - Medical scheme claim statement/remittance advice Claims must be submitted within 6 months after the event Claims received after 6 months will be considered a stale claim and will be rejected Claim forms are available and can be downloaded. Claims are paid on the 3rd working day of every month
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