Who can apply for Gap Cover?
Anyone who is a member of a registered South African medical aid and meets the requirements of an Eligible Member (please speak to a consultant for the full definition of an Eligible Member) can apply. Members on different medical aids can be covered on the same Trulogic Gap Cover policy.
What am i covered for?
The following are seen as covered events: hospitalisation for accidental harm, illness or other health incidents; oncology treatment, including chemotherapy, radiotherapy or other drug regimen. Should you experience a physical trauma event, there is an allowance for treatment in a casualty ward.
What are the co-payment cover benefits?
Cover is provided for procedural co-payments (the excesses imposed in terms of your medical aid rules) for procedures performed as an in-patient or an out-patient, including MRI, CT, PET, SPECT and Ultrasound Scans (A full list of the defined procedures is available from here.)
How much cover do I get?
The total cover amount is R158 000 per beneficiary, per year. This annual limit includes in-hospital costs, as well as some out-of-hospital costs.
What am I not covered for?
- Gap Cover doesn’t cover procedures that aren’t covered by your medical aid.
- Gap Cover doesn’t include benefits for PMB claims. Prescribed Minimum Benefits (PMBs) are a set of defined benefits to ensure all medical aid members have access to certain minimum health services, regardless of the benefit option they have selected.
- Normal visits to your general practitioner or specialist, and auxiliary services on a day-to-day basis are not part of your policy benefit.
Do I have to go for a medical examination to qualify?
No. Cover is available immediately, subject to relevant waiting periods. However, underwriting may be applied at claim stage.
Can I cover my family?
Trulogic Gap Cover provide benefits for members and their dependants (spouse and/ or child/children) who are covered on one policy of a registered medical aid scheme. Members and their dependants can only be on two different medical aids and one Gap Cover Policy if they are legally married, or common law partners verified by submission of an affidavit confirming 12 months of co-habitation.
Common Law partners need to provide an affidavit proving 12 months of cohabitation for membership to be considered.
Is there an age limit?
There is no entry age limit.
Is there a waiting period?
There is no general 3 month waiting period. 10 Month condition specific waiting period: No claims may be submitted within the first 10 months of membership for any Gap Cover policy if they relate to any of the following conditions:
Head, neck and spinal procedures (including stimulators) e.g. Laminectomy
- All types of hernia procedures
- Endoscopic procedures e.g. Colonoscopy, Gastroscopy
- Oesophagitis, Gastroenteritis and Gastro-Intestinal Disorders
- Pregnancy and childbirth (including caesarean delivery)
- Gynaecological conditions e.g. Hysterectomy
- Male genital system (including prostatectomy / robotic prostatectomy)
- All robotic type surgery
- Joint replacement (including Arthroplasty, Arthroscopy, Metatarsal Osteotomy) but
excluding treatment due to accidental trauma.
- Inability to walk / move without pain
- Any Ear, Nose and Throat procedures (including nasal, sinus, tonsil and adenoid procedures)
- Cardiac (relating to the heart)
- Dentistry (unless due to accidental trauma)
- Cataracts and / or eye laser surgery (including all eye and lens procedures)
- Neurological conditions and procedures (including stimulators)
- Organ transplants (including cochlear implants)
- Renal Failure
- Reconstructive surgery as a result of an incident or condition that occurred prior to
membership (including skin grafts)
- Mental health or psychiatric conditions (including depression)
- Varicose veins
- Diabetes and related complications
All claims for these conditions received within the waiting period will be reviewed by medical management to identify pre-existing conditions.
What is the waiting period for cancer diagnoses?
If a Policyholder is diagnosed with any form of cancer prior to membership, all related claims will be subject to a nine (9) month waiting period. If a Policyholder has previously been diagnosed with cancer and is currently in remission, the Policyholder needs to advise the insurer by way of medical evidence that the remission period has been for two (2) or more consecutive years.
What is the waiting period for pre-existing medical conditions?
No claims relating to any pre-existing condition/s that may lead to hospitalisation (excluding cancer: see above) will be covered within the first six (6) months of membership. The insurer reserves the right to request any clinical information from a Policyholder’s doctor should a claim in this period indicate, and/or relate to, a pre-existing condition. All claims for these conditions received within the waiting period will be reviewed by medical management to identify pre-existing conditions.
How do I claim?
Submit your claims documents via the mobile app.
What is a medical aid rate?
The Council for Medical Schemes recommends a rate medical practitioners should charge for medical procedures. This recommended rate is the medical aid rate, used by medical aids to determine what to reasonably pay medical practitioners for medical procedures performed on the medical aid’s members.
Can I get Gap Cover if I don't have a medical aid?
No. Gap Cover isn’t a medical aid and the cover is not the same as that of a medical aid. This policy is not a substitute for medical aid membership.