Frequently Asked Questions

• Overall Annual Limit (OAL) - R150 000 per insured per annum
• Increases Medical Aid rates up to 600% for in-hospital treatments
• Co-payment Cover
• Non-DSP Hospital Penalty Cover
• Sub-limit Cover
• Traditional and Biological Cancer Drug Cover
• Casualty Benefit

A Medical Expense Shortfall is the difference between what medical service providers (e.g. Doctors, basic and specialised Radiology, Pathology, Specialists) charge and what Medical Schemes pay for the treatment performed in hospitals and day clinics, provided that it is paid from the Hospital Benefit of your Medical Scheme.

Medical Expense Shortfall Cover will boost your Medical Aid rate, helping you with this shortfall!

Below is an example of a claim for a Hip replacement

A co-payment or deductible is an upfront amount that needs to be paid to the hospital/day clinic /radiologist before undergoing certain procedures, as specified by your Medical Scheme

When you experience a co-payment for a procedure or scan (as specified by your Medical Scheme) you would need to pay for the co-payment up-front and then claim the amount back from your MediGap Prestige policy (provided that the plan you selected offers a co-payment benefit)

If your Medical Scheme pays for co-payments from your day to day benefits you may still claim the amount back from your MediGap Prestige policy.

Should you choose to go to a hospital or day clinic outside of your Medical Schemes Hospital Network/Designated Service Providers, you would be liable for a portion of the account,as specified by your Medical Scheme.

Example:

Johnny’s Medical Scheme stipulates that he needs to go to hospital X, if :

He chooses to go to another hospital he would need to pay the first R8 000 of the hospital account. Johnny chooses to go to hospital Y and pays the R8 000 and then claims it back from his MediGap Prestige policy

When a Medical Scheme will only pay for a certain procedure, prosthetic device or scan up to a specified limit, this is a sub-limit.

Example:

Joe gets admitted to hospital for a hip replacement. After the procedure he notices that the cost of the prosthetic hip was R60 000, but his Medical Scheme only paid R50 000 towards the prosthetic hip, leaving him liable for R10 000.

Luckily for Joe, he has a MediGap Prestige policy that offers sub-limit cover of R20 000 per admission per insured. Subject to the Overall Annual Limit

Therefore Joe can submit the account to MediGap to pay the R10 000 the difference from his MediGap Prestige Policy.

If you have depleted your Cancer benefit on your Medical Scheme, you may become liable for co-payments or the full cost of any further Cancer treatment, as specified by your Medical Scheme.

Example 1:

Kathy has finished her R250 000 Cancer benefit available to her on her Medical Scheme and now she is liable for the full cost of her Cancer treatment.

Kathy still needs to undergo chemotherapy sessions. Luckily, she has a MediGap Prestige policy and she can submit the cost of her further chemotherapy sessions to MediGap

Example 2:

Deon has finished his R250 000 Cancer benefit available to him on his Medical Scheme and still needs to undergo chemotherapy. His Medical Scheme will pay for 80% of the account for his chemotherapy . Deon is glad he listened to his Financial Advisor and took our a MediGap Prestige policy, now be can submit the account to Easy Gap.

When you require treatment with Biological Cancer Drugs your Medical Scheme may only pay for them up to a certain limit.

Example:

John’s Medical Scheme paid for the Biological Cancer Drugs he required up to a limit , thereafter he was liable for the full cost of his Biological Cancer Drugs.

John was grateful that he took out a MediGap Prestige policy and he submitted the rest of the account for his Biological Cancer Drugs to MediGap

Medical expense shortfall cover

• Increases the medical aid rate up to 600% for example specialist, gps, anaesthetist, radiology, pathology etc
• Subject to the overall annual limit

Co-payment cover

• R75 000 per admission per insured
• Subject to the overall annual limit

Non-dsp hospital penalty cover

• R9 000 per admission. Limited to 1 claim per family per annum
• Subject to the overall annual limit

Sub-limit cover

• R20 000 per admission per insured
• Subject to the overall annual limit

Traditional cancer cover

• Pays for treatment in a private facility, including sub-limits, deductibles or co-payment related to cancer treatment (R200 000 excess)
• Subject to the Overall Annual Limit

Biological cancer drug cover

• Provides cover for Biological Cancer Drugs when the Medical Scheme imposes a sub-limit
• Subject to the Overall Annual Limit ( See Formulary)

Biological cancer drugs

• The list below provide the cancer types that may require treatment through the use of a biological cancer drug covered under Easy Complete

Specific cancer categories

LIST OF DRUGS

• Herceptin
• Nexavar
• Sprycel
• Tarceva
• Zevalin
• Erbitux
• Fludara
• Myelodysplasia
• Mylotarg
• Gleevec
• Velcade
• Alimta
• Avastin
• Sutent
• Mabthera

Co-payments for mri, ct and pet scans

• R75 000 per admission per insured
• Subject to the overall annual limit

Sub-limit cover for mri, ct and pet scans

• R20 000 per admission per insured
• Subject to the overall annual limit

Casualty benefit(accidents only)

• R12 000 per event per insured
• Subject to the overall annual limit

Cancer diagnosis benefit

• Once off payment of r20 000 for first diagnosis of cancer, provided that the insured is on an approved oncology treatment plan

Medical scheme contribution waiver

• Up to r5 500 per month for 6 months, in the event of death or permanent and total disability as a result of an accident, of the medical scheme contribution payer

Gap premium waiver

• Pays the premium for your easy gap complete policy for 6 months, in the event of death or permanent and total disability as a result of an accident, of the contribution player

Personal accident benefit

• R25 000 per insured on the policy, in the event of accidental death or permanent and total disability

International travel cover

• R5 000 000 per insured

• A 3-month general waiting period applys to all benefits, with exception of benefits providing cover up to 600% should the commencement of the Policy be in line with the commencement date of the Medical Scheme. Accidents will be covered with in the 3 month general waiting period.
• A 10-month waiting period on pregnancy/childbirth
• A 12-month waiting period on/investment, treatment or surgery for: hysterectomy (except where malignancy can be proven) , hysteroscopies, endometriosis, ovarian cysts and fibroids ( myomectomy), muscular-skeletal, tonsillectomy, myringotomy, grommets, adenoids, wisdom teeth, hernia, cataracts, gastroscopies, colonoscopies, cancer, nasal and sinus

You can download our Exclusion document here.

• Overall Annual Limit (OAL) - R150 000 per insured per annum
• Increases Medical Aid rates up to 500% for in-hospital treatment
• Co-payment Cover
• Non-DSP Hospital Penalty Cover
• Sub-limit Cover
• Casualty Benefit

A Medical Expense Shortfall is the difference between what medical service providers (e.g. Doctors, basic and specialised Radiology, Pathology, Specialists) charge and what Medical Schemes pay for the treatment performed in hospitals and day clinics, provided that it is paid from the Hospital Benefit of your Medical Scheme.

Medical Expense Shortfall Cover will boost your Medical Aid rate, helping you with this shortfall!

Below is an example of a claim for a Hip replacement

A co-payment or deductible is an upfront amount that needs to be paid to the hospital/day clinic /radiologist before undergoing certain procedures, as specified by your Medical Scheme

When you experience a co-payment for a procedure or scan (as specified by your Medical Scheme) you would need to pay for the co-payment up-front and then claim the amount back from your MediGap Prestige policy (provided that the plan you selected offers a co-payment benefit)

If your Medical Scheme pays for co-payments from your day to day benefits you may still claim the amount back from your MediGap Prestige policy.

Should you choose to go to a hospital or day clinic outside of your Medical Schemes Hospital Network/Designated Service Providers, you would be liable for a portion of the account,as specified by your Medical Scheme.

Example:

Johnny’s Medical Scheme stipulates that he needs to go to hospital X, if :

He chooses to go to another hospital he would need to pay the first R8 000 of the hospital account. Johnny chooses to go to hospital Y and pays the R8 000 and then claims it back from his MediGap Prestige policy

When a Medical Scheme will only pay for a certain procedure, prosthetic device or scan up to a specified limit, this is a sub-limit.

Example:

Joe gets admitted to hospital for a hip replacement. After the procedure he notices that the cost of the prosthetic hip was R60 000, but his Medical Scheme only paid R50 000 towards the prosthetic hip, leaving him liable for R10 000.

Luckily for Joe, he has a MediGap Prestige policy that offers sub-limit cover of R20 000 per admission per insured. Subject to the Overall Annual Limit

Therefore Joe can submit the account to MediGap to pay the R10 000 the difference from his MediGap Prestige Policy.

Medical expense shortfall expense

• Increases the medical aid rate up to 500% for example specialist, gps , anaesthetist , radiology , pathology etc
• Subject to the overall annual limit

Co-payment cover​

• R50 000 per admission per insured
• Subject to the overall annual limit

Non-dsp hospital penalty cover

• R5 000 per admission. Limited to 1 claim per family per annum
• Subject to the overall annual limit

Sub-limit cover

• R15 000 per admission per insured. Limited to r50 000 per family per annum
• Subject to the overall annual limit

Co-payment for mri, ct and pet scans

• R50 000 per admission per insured
• Subject to the overall annual limit

Casualty benefit (accidents only)

• R6 500 per event insured.
• Subject to the overall annual limit

Medical scheme contribution waiver

• Up to r5 500 per month for 6 months, in the event of death or permanent and total disability as a result of an accident, of the medical scheme contribution payer

Gap premium waiver

• Pays the premium for your easy gap boost policy for 6 months, in the event of death or permanent and total disability as a result of an accident, of the contribution payer

International travel cover

• R5 000 000 per insured

• A 3-month general waiting period applys to all benefits, with exception of benefits providing cover up to 600% should the commencement of the Policy be in line with the commencement date of the Medical Scheme. Accidents will be covered with in the 3 month general waiting period.
• A 10-month waiting period on pregnancy/childbirth
• A 12-month waiting period on/investment, treatment or surgery for: hysterectomy (except where malignancy can be proven) , hysteroscopies, endometriosis, ovarian cysts and fibroids ( myomectomy), muscular-skeletal, tonsillectomy, myringotomy, grommets, adenoids, wisdom teeth, hernia, cataracts, gastroscopies, colonoscopies, cancer, nasal and sinus

You can download our Exclusion document here.

• Overall Annual Limit (OAL) - R150 000 per insured per annum and an excess of R350 per event
• Increases the Medical Aid rate up to 350% for in-hospital treatments.
• Casualty Benefit

A Medical Expense Shortfall is the difference between what medical service providers (e.g. Doctors, basic and specialised Radiology, Pathology, Specialists) charge and what Medical Schemes pay for the treatment performed in hospitals and day clinics, provided that it is paid from the Hospital Benefit of your Medical Scheme.

Medical Expense Shortfall Cover will boost your Medical Aid rate, helping you with this shortfall!

Below is an example of a claim for a Hip replacement

Medical expense shortfall expense

• Increases the medical aid rate up to 350% for example specialist, gps, anaesthetist, radiology, pathology etc
• Subject to the overall annual limit and an excess of r350 per event

Casualty benefit (accidents only)

• R3 000 per event per insured. Subject to the overall annual limit and an excess of r350 per event

Medical scheme contribution waiver

• Up to r5 500 per month for 6 months, in the event of death or permanent and total disability as a result of an accident, of the medical scheme contribution payer

Gap premium waiver

• Pays the premium for your launch policy for 6 months, in the event of death or permanent and total disability as a result of an accident,of the contribution payer

International travel cover

• R5 000 000 per insured

• A 3-month general waiting period applys to all benefits, with exception of benefits providing cover up to 600% should the commencement of the Policy be in line with the commencement date of the Medical Scheme. Accidents will be covered with in the 3 month general waiting period.
• A 10-month waiting period on pregnancy/childbirth
• A 12-month waiting period on/investment, treatment or surgery for: hysterectomy (except where malignancy can be proven) , hysteroscopies, endometriosis, ovarian cysts and fibroids ( myomectomy), muscular-skeletal, tonsillectomy, myringotomy, grommets, adenoids, wisdom teeth, hernia, cataracts, gastroscopies, colonoscopies, cancer, nasal and sinus

You can download our Exclusion document here.

Medical Emergency Expenses are covered up to the Benefit Limit

YOU are covered for an Unexpected Complication(s) arising whilst YOU are undergoing the "Elected Procedure" or occurring during the Recovery Period and requiring an Emergency Procedure to be undergone by YOU the Insured Person.

The “Elected Procedure” means any cosmetic medical procedure undertaken by YOU, performed by a Medical Practitioner and the costs of which, or any procedures resulting therefrom, are not paid by a Medical Scheme.

Emergency Medical Expenses or costs shall mean all actual expenses necessarily incurred by YOU in respect of the Emergency Procedure, within 3 (three) months of the completion of the Elected Procedure;

The “Emergency Procedure” means a medical procedure or treatment, which a Medical Practitioner in his/her professional opinion believes to be necessary to treat an Unexpected Complication.

The Insurers shall not be liable to pay YOU the Insured Person in respect of claims:

1. due to alleged or proven medical malpractice or negligence by the Medical Practitioner performing the Elected or Emergency Procedure;
2. for Medical Expenses incurred in administering and performing the Elected Procedure for which YOU were admitted;
3. for Medical Expenses incurred for any subsequent surgery or procedure(s) undertaken byYOU with the aim of:
   1. improving the Elected Procedure, or
   2. acquiring the effect originally intended or desired from the Elected Procedure; or
   3. restoring YOU to YOUR physical appearance as prior to the Elected Procedure; and which does not fall within the ambit of Emergency Procedure;
4. directly or indirectly caused by, contributed to or arising from ionising radiations or contamination by radioactivity;
5. for costs incurred for rest cures, janitorial or custodial care or periods of quarantine or isolation;
6. for and/or arising out of, caused by or contributed to by suicide (or any attempt thereat) or intentional self-injury or exposure to obvious risk of injury (unless sustained in an attempt to save human life);
7. where YOU have not complied with all medical advice for treatment and/or precautions to be followed by YOU during the Recovery Period;
8. arising from the unreasonable or wilful neglect or failure by YOU to seek and remain under the care of a qualified member of the medical profession once Unexpected Complications manifest.

If the Insurers allege that by reason of this Exclusion, any claim is not covered by this Policy, the burden of proving the contrary shall be upon YOU