Product overview. Gap Cover benefits

Transcription

1 Gap Cover Plus 2015

2 Product overview Most medical schemes will cover in-hospital expenses defined as services rendered by a medical practitioner at the medical scheme tariff. However, most specialists today are charging rates that are substantially higher than the medical scheme tariff and you, as the member will be liable for the difference. Gap cover is an insurance product that provides cover for you and your dependants, registered under your medical scheme for the shortfall (GAP) resulting from any medical/ surgical procedure charged above the benefit paid by your medical aid for incidents that necessitate hospitalisation. Gap Cover benefits The insured will receive a benefit equivalent to the costs incurred as a result of the GAP for any hospital admission as an inpatient. The GAP is defined as services rendered by a medical practitioner who charges above the medical scheme tariff Gap cover is a benefit equal to actual cost limited to five (5) times the medical scheme tariff less the medical scheme tariff for treatment received whilst as an inpatient and/or outpatient. In-hospital co-payment cover is a benefit equal to the charges in the form of a copayment or deductible applied for treatment received whilst as an in-patient and/or outpatient. Sub-limitation cover is a benefit equal to charges above any sub-limitation imposed by the medical scheme for treatment received whilst as an in-patient and/or outpatient. Certain surgical procedures that are traditionally performed in-hospital that are performed in Doctor s Rooms will also be covered e.g. certain scopes. Benefits exclude ward fees, theatre fees, medicines, materials and other hospital expenses. Gap Cover Plus 1

3 Major medical co-payment / deductible cover Charges in the form of a co-payment or deductible applied for in-hospital admissions/or the necessity for chemotherapy of radiotherapy for the treatment of cancer on an out-patient basis and/or the necessity for kidney dialysis on an out-patient basis; Additional benefits on Gap cover Plus Charges in the form of a co-payment or deductible for major medical outpatient treatment limited to specialised diagnostic radiology limited to MRI and CT Scans. Such co-payment or deductible amounts applied as per the rules of the principal s registered medical scheme. Benefits exclude ward fees, theatre fees, medicines, materials and other hospital expenses. Oncology benefit This benefit will provide cover where the scheme may limit or impose a co-payment on cancer treatment for traditional treatment or treatment that includes the use of biological drugs. The sub-limitation and/or co-payment imposed by the medical scheme for cancer, either for traditional cancer treatment or biological drugs, with an excess of R200, 000 for each 12 month period and limited to R100, 000 per insured person per annum. The benefit for biological drugs is limited to specific drugs; Herceptin, Mylotarg, Nexavar, Gleevec, Sprycel, Faslodex, Velcade, Tarceva, Alimta, Zevalin, Avastin,Erbitux, Sutent, Fludara and Mabthera. Gap Cover Plus 2

4 The benefit is limited with specific oncological conditions and / or specific sub groups of cancers limited to subgroups of the following categories; HER2 Breast cancer and HER Breast cancer Advanced hepatocellular carcinoma Chronic myeloid leukemia Hairy cell leukemia Gastrointestinal stromal tumour Non small cell lung cancer Metastatic colorectal cancer Head and neck cancer Acute myeloid leukemia Acute lymphoblastic leukemia Chronic lymphocytic leukemia Myelodysplasia Multiple myeloma Non-hodgkins lymphoma Advanced renal cell carcinoma A pre existing condition clause has been imposed on this benefit. The illness has to manifest itself during cover for a benefit to be paid. The pre existing exclusion is waived for members that are already on the Gap Plus and the cancer manifested itself during the period of cover. Please note that this product will assist with the shortfalls for in-hospital expenses and does not provide cover for day-to-day expenses once your Medical Savings Account has been depleted, nor will it cover your expense if you are in the self-payment gap. Limitations The maximum benefit payable in terms of this policy shall be as follows: R1 million per family per annum Gap Cover Plus co payment limits Benefits for co-payments or deductibles are limited to R30, 000 per insured per person per annum and R50, 000 per family per annum. Gap Cover Plus 3

5 Gap Cover Plus sub limitations Benefits for charges above any sub limitations (other than for biological drugs for cancer treatment) are limited to R30, 000 per principal insured per annum. The sub-limitation and/or co-payment imposed by the medical scheme for cancer, either for traditional cancer treatment or biological drugs, with an excess of R200, 000 for each 12 month period and limited to R 100, 000 per insured person per annum. Actual example: Total knee replacement Charged Medical aid benefit Gap Cover Anesthetist Pre-op exam Total knee replacement Time Procedure for pain relief R R R 4, R R R R 1, R R R R R Total R 6, R 2, R 4, Specialist Total knee replacement Assistant fee Total Physiotherapy R 11, R 2, R 14, R 3, R R 4, R 7, R 1, R 9, In-hospital treatment R 1, R R Total R 1, R R Total benefit R 22, R 7, R 14, In this example, the medical scheme member would have been out of pocket for R equivalent of 65% of the total knee replacement costs. Gap Cover Plus 4

6 Terms of cover Cover shall only be in force provided that the Insured Person is a member on a registered medical aid scheme. No benefit shall be payable in respect of any medical or surgical treatment unless such a treatment occurred during the period of hospital confinement. The minimum entry age for the Principal insured person is age eighteen (18) last birthday. Dependents turning 21 can remain on the policy up until the age of 25 provided that they are full time students and proof thereof is submitted. The maximum entry age is seventy (70) last birthday. Standard exceptions No benefits are payable for hospitalisation, injury or illness directly or indirectly caused by or in consequence of; Nuclear weapons or nuclear material or by ionising radiation. Investigations, treatment or surgery for obesity, its sequelae or cosmetic surgery Any claim not covered by the Medical Scheme as well as any procedure of a purely diagnostic nature. Suicide, attempted suicide or intentional self-injury. The taking of any drugs or narcotics unless prescribed by and taken in accordance with the instructions of a registered medical practitioner. An event directly attributable to the Insured Person being under the influence of drugs or alcohol. An insured event within the first 12 months of cover for which the insured person received treatment or advice 12 months prior to inception. Pregnancy or childbirth for the first 12 months of cover. Infertility. Depression, insanity or mental stress or psychotic/psychoneurotic disorders. Fraudulent claims. Participation in: Active military duty, policy duty, police reservist duty, civil commotion, labour disturbances, strike or the activities of locked-out workers. Aviation other than as a passenger. Any form of race or speed test (other than on foot or involving any nonmechanically propelled vehicle, vessel, craft of aircraft). Gap Cover Plus 5

7 Monthly premiums The individual rate for the Gap Cover Plus will be R172 per family per month. Should you be joining as part of an employer group, please contact your Sasfin Healthcare consultant to confirm the applicable rate that will be applied. Claiming procedures Claim forms are obtainable from Sasfin Healthcare or Ambledown and should be returned to: Ambledown Risk and Underwriting Managers (Pty) Ltd P O Box 1862 CRAMERVIEW 2060 Alternatively, claims can be sent via to claims@ambledown.co.za To claim from Gap Cover you need to complete a claim form and submit copies of the following documentation along with the form: Hospital accounts; Doctors accounts; and Medical aid statement It is very important that Ambeldowns be notified of the claim within 180 days after the hospital admission. Once the claim has been submitted, should you have any queries on the Gap Cover claim you can contact Ambledowns on This policy will not provide cover for expenses listed as exclusion on your medical aid option. Enquiries Enquiries should be addressed to Ambledown: Tel: Fax: admin@ambledown.co.za The information provided herein is meant for general purposes only and is not intended to be construed as professional advice. If professional advice or expert assistance is required, you may consult with your Sasfin Healthcare consultant. Sasfin Healrthcare Consulting is a division of Sasfin Financial Advisory Services (Pty) Ltd - an authorised financial services provider FSP No 5711 / CMS No. Org 544.