This option is designed to provide additional cover for tariff shortfalls on doctors and specialists accounts for in-hospital procedures as well as cover for procedure related co-payments imposed by a medical scheme.
MONTHLY PREMIUM 2016
INDIVIDUAL . . . . . . . . . . . . . . . R 185
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 toR12 000 per insured per annum
- Consumable items, limited to R6 000 per insured per annum
- Physiotherapy, limited to R6 000 per insured per annum
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 limited to R40 000 per policy per annum
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 R3 500 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 R3 000 per policy per annum
APPLICABLE FROM INCEPTION OF THE POLICY
- 3 Months general waiting period (no claims can be submitted within the first 3 months of cover unless accidental)
- 6 Months waiting period for tonsillectomy, myringotomy (grommets), adenoidectomy, hysterectomy (except where cancer is diagnosed), joint replacements (unless accidental), hernia repairs (unless an emergency), cataract surgery, endoscopic procedures and related surgery and dental
- 10 Months waiting period for pregnancy and childbirth
- 10 Months waiting period for pre-existing medical conditions and related surgery
- Entry age before 70th birthday
- 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