Gap Cover Option

Compare Gap Cover Options Base 500 Co-Evolution 500 Comprehensive Elite Senior 500 Hospital Optimiser Oncology Plus G Force Corporate Elite Stratum Corporate Elite (EXCLUSIVELY TAILORED FOR CORPORATE EMPLOYER GROUPS ONLY) This option is designed to provide additional cover for tariff shortfalls on doctors and specialists accounts for in-hospital procedures, cover for procedure related and oncology co-payments and where sub-limits on biological drugs and in-hospital procedures are imposed by a medical scheme.

MONTHLY PREMIUM

Subject to the demographic profile of the group
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   Stratum Corporate Elite

Gap Cover Insurance for the business Gap Cover Insurance for the business
Product Stratum Corporate Elite / Group quotation
   
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OVERVIEW

GAP BENEFIT

This benefit provides additional cover of 500% above the medical scheme rate. • Benefit is unlimited GAP BENEFIT also includes cover for tariff shortfalls for certain in-hospital related accounts: • Radiology (x-rays) and pathology, limited to R12 000 per insured per annum • Consumable items, limited to R6 000 per insured per annum • Physiotherapy, limited to R6 000 per insured per annum

CO-PAYMENT BENEFIT

This benefit provides cover for co-payments and deductibles imposed by a medical scheme. Co-payments/Deductibles: “An upfront payment that is required by a medical scheme for the cost of certain procedures.” • Covers all compulsory co-payments for in-hospital procedures, MRI and CT scans    (in- and out of hospital) as well as hospital pre-admission co-payments (no    benefit if a non-designated service provider is utilised) • Benefit is unlimited

ONCOLOGY BENEFIT

This benefit provides additional cover for oncology related co-payments and where a sub-limit on biological drugs is imposed by a medical scheme. • Benefit for co-payments and biological drugs (as per the Stratum Benefits    formulary) is limited to R450 000 per policy per annum • A once-off benefit of R5 000 per insured life is payable after policy inception on    the first diagnosis of cancer, as per the Stratum Benefits recognised Cancer    Categories RECONSTRUCTION BENEFIT, due to a mastectomy, covers the tariff shortfalls up    to 300% of the medical scheme rate, provided that cancer is diagnosed after   inception of the Stratum Benefits policy
Gap Cover Insurance for the business

SUB-LIMIT BENEFIT

This benefit provides additional cover when a sub-limit benefit on a medical scheme option has been reached. Sub-limit: “The limit imposed by a medical scheme for specific in-hospital procedures, but excludes overall annual limits.” • Benefit is limited to R20 000 per event to a maximum of R60 000 per insured per annum

ADDITIONAL BENEFITS

GAP POLICY PREMIUM WAIVER BENEFIT covers the monthly premium for a period of 12 months in the event of death, permanent disability or    forced retrenchment of the premium payer where the premium payer is a natural person MEDICAL SCHEME CONTRIBUTION WAIVER BENEFIT covers the monthly scheme contribution, limited to R4 000 per month per insured family,    for a period of 6 months in the event of death or permanent disability of the premium payer where the premium payer is a natural person  ACCIDENTAL DEATH BENEFIT covers the lives of the principal insured and spouse, limited to R5 000 per life and R3 000 per child dependant

CASUALTY BENEFIT

This benefit covers the expenses that may occur at a registered casualty facility for treatment required due to an accident. Accident: “Bodily injury caused by violent, accidental and external physical means.” • Benefit is limited to R5 000 per policy per annum

TRAUMA COUNSELLING BENEFIT

This benefit covers counselling sessions with a registered counsellor or clinical psychologist that may be required after a serious or traumatic event due to violence, an accident or on the diagnosis of a dread disease, restricted to the insured lives on the Stratum Benefits policy. Trauma: “A serious injury or shock to the body due to violence, an accident or on the diagnosis of a dread disease that may cause substantial psychological damage.” • Benefit is limited to R5 000 per policy per annum

UNDERWRITING CRITERIA

APPLICABLE FROM INCEPTION OF THE POLICY

• Subject to the demographic profile of the group

GENERAL

• Children will be accepted as child dependants up to and including the age of 27, provided they are registered dependants on the medical    scheme option of either the principal member or the spouse • From the age of 28, a child dependant will be regarded as an adult and will therefore be charged an adult dependant rate, provided that the    dependant is registered on the medical scheme option of either the principal member or the spouse • Entry age for adult dependants before 70th birthday • The Stratum Benefits policy extends cover to all dependants as registered on the medical scheme option of either the principal member or the    spouse

STRATUM BENEFITS FORMULARY LIMITED TO

Herceptin, Mylotarg, Nexavar, Gleevec, Sprycel, Faslodex, Velcade, Tarceva, Alimta, Zevalin, Avastin, Erbitux, Sutent, Fludara, Mabthera with specific oncological condition and/or specific sub-groups of cancers limited to the sub-groups of the following Cancer Categories: HER 2 + Breast cancer, Acute myeloid leukemia, Advanced hepatocellular carcinoma, Acute lymphoblastic leukemia, Chronic myeloid leukemia, Chronic lymphocytic leukemia, Non-Hodgkins lymphoma, Advanced renal cell carcinoma, Hairy cell leukemia, Myelodysplasia, HER-ve breast cancer, Gastrointestinal stromal tumor, Multiple myeloma, Non-small cell lung cancer, Metastatic colorectal cancer and Head and neck cancer

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Gap Cover

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