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 a sub-limit on biological drugs is imposed by a medical scheme.
MONTHLY PREMIUM 2016
INDIVIDUAL . . . . . . . . . . . . . . . . . . . . . . . . R 167
FAMILY . . . . . . . . . . . . . . . . . . . . . . . . . . . . R 205
PER ADULT DEPENDANT . . . . . . . . . . . R 60
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 R60 000 per policy per annum
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 R350 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
- GAP POLICY PREMIUM WAIVER BENEFITcovers 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 3 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
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 R4 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 R4 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 procedures
- 10 Months waiting period for pregnancy and childbirth
- 10 Months waiting period for pre-existing medical conditions and related surgery
- A total exclusion for any pre-diagnosed cancer is applicable to the Oncology Benefit
- 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
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