MediGap Proper

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.