Frequently Asked Questions
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Medical Shortfall Insurance
What is Medical Shortfall Insurance?
- Medical shortfall insurance Insurance provides cover for the shortfall between what a medical practitioner charges and what your medical aid pays, for any in-hospital surgical procedure or for certain out-of-hospital surgical procedures.
What is my cover limit?
- This product offers you an annual cover limit of R150,000.00 per person listed on the policy.
NB* The members insured under this policy must be listed on your medical aid certificate as an insured person in order to be considered as covered.
Can I purchase this as a replacement for my medical aid?
- No, Gap cover is not a substitue for medical aid.
- This product can only be acquired if you are a registered member of a medical aid.
What is NOT covered?
The Insurers shall not be liable to pay Compensation in respect of any Insured Person
- for any Pre-Existing Condition.
- as a result of attempted suicide or self inflicted injury.
- as a result of the Insured Person being under the influence of alcohol, drugs or narcotics unless such alcohol, drugs or narcotics were administered by a Physician or unless prescribed by and taken in accordance with the directions of a Physician.
- as a result of participation in any riot or civil commotion or public disorder.
- for Bodily Injury whilst or as a result of participating in a Professional Sport.
- where the Insured Person at any time suffered from the condition commonly known as AIDS or was infected by the commonly called HIV virus. The terms “AIDS” and “HIV” shall be interpreted as broadly as possible so as to include all or any mutants, derivatives or variations thereof. The onus shall always be on the Insured Person to show that any event was not caused by or did not arise through AIDS or HIV.
- for Illness resulting from or due to venereal or venereal-related disease, or for the costs of treatment for any sexually transmitted disease.
- for investigations or exploratory procedures paid by the Medical Scheme on an ex-gratia basis.
- for operations or treatment of a purely cosmetic nature.
- for treatment of obesity.
- for treatment undertaken to facilitate pregnancy.
- for treatment of psychotic or psychoneurotic disorders; unless directly arising out of an incident of Bodily Injury or Illness.
- directly or indirectly occasioned by or happening through or in consequence of nuclear weapon material or by ionising radiations or contamination by radioactivity from any nuclear fuel or from any nuclear waste from combustion of nuclear fuel. For the purpose of this Exclusion, combustion shall include any self-sustaining process of nuclear fission.
- for any condition where the member has ignored medical advice.
- as a result of war, invasion, act of foreign enemy, hostilities or warlike operations (whether war be declared or not) or civil war.
- for any ward fees, bed levies or theatre fees and all medicines and consumables utilised in the ward or theatre.
- for complications during pregnancy or for childbirth within 12 months of inception of cover.
- for any external prosthesis or dental implants.
- for any claims not covered by the Medical Scheme or for claims paid by the Medical Scheme on an ex-gratia basis.
Emergency Medical Insurance
Am I insured against ANY procedure?
Can I use any medical practitioner within South Africa?
If my procedure is R10,000, but I am insured for R30,000, does the entire insurance amount get paid out?
What documents do you require from me to apply for insurance?
How do I claim?
How long does it take for a claim to be paid out?