2024 Cura Gap Advanced Plus Cover
Gap Cover is an Insurance Product that provides cover for you and your immediate family for the shortfall (Gap) resulting from any Medical Practitioner charging above the Medical Scheme Tariff for in-hospital surgical procedures and certain out of hospital procedures.
Our Gap Advanced PLUS cover is designed and priced for middle aged families with teen children who need more comprehensive benefits. With the addition of the Gap Advanced Plus option, we were able to introduce more comprehensive benefits and keep the premium competitive as well as bring the premiums closer together for members wanting a higher level of, comprehensive cover. It ensures you and your family are covered for the most common types of claims and covers medical expense shortfalls of up to 500%.
This is not a medical scheme, and the cover is not the same as that of a medical scheme. This policy is not a substitute for medical scheme membership.
What does Cura Gap Advanced Plus Cover entail?
| cover | annual limit | Benefit description |
|---|---|---|
|
Overall Annual Limit (OAL) of R201 000 per Insured (Limits are subject to regulatory amendments) |
||
| Gap Cover | Up to 500% |
The shortfall that arises after your medical aid has processed your account, as a result of the service providers charging above scheme tariff for authorised in-hospital procedures. The benefit pays up to 500% of scheme tariff less the higher of the amount paid by the scheme or the scheme tariff for in-hospital procedures/treatment and certain specified out-of-hospital procedures/treatments. You must belong to a registered South African medical scheme to qualify for Gap Cover. |
| Cover for all Prescribed Minimum Benefits (PMB’s) |
Cover for PMB's |
A set of defined benefits, as per the Medical Schemes Act, in terms of which all medical schemes must cover the costs related to the diagnosis, treatment and care of any emergency medical condition; a limited set of 270 medical conditions; and 27 chronic conditions. |
|
In-hospital Co-payments / Deductibles (Includes out-of-hospital MRI and CT scans) |
R201 000.00 per Insured per annum. | 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 Cura Gap Policy. If your Medical Scheme pays for co-payments from your day-to-day benefits, you may still claim the amount. This benefit includes out-of-hospital MRI/CT scans. |
|
Co-payment: Non-DSP Hospital |
R12 000 per Policy |
The use of a Non-DSP hospital which results in a co-payment will be covered up to R10 000 per family per annum. |
|
Sub-limitations |
R25 000 per Policy |
A benefit equal to charges above any sub-limitation imposed by the Medical Scheme for treatment received whilst as an in-patient. |
|
Internal Prosthesis |
Included in R25 000 Sub-Limit |
The shortfall on a service provider account that is not covered where you have reached the sub-limit for Internal Prosthesis imposed by your medical scheme AND which has been authorised and paid from the In-Hospital or Major Medical benefit. It covers the difference in Internal prosthesis (examples include hips, knees, and spinal prosthesis, Cochlear Implants, and even cardiac pacemakers. |
|
Sub-limitations on Intra - Ocular Lenses |
R9 000 per lens per year |
The shortfall on a service provider account that is not covered where you have reached the sub-limit for Intra-Ocular lenses imposed by your Medical Scheme AND which has been authorised and paid from the In-Hospital or Major Medical benefit. |
|
Radiology and Pathology Services |
R12 000 per Policy |
Combined capped amount where a member's available out of hospital benefits are depleted. This benefit provides an amount of R12 000 per family per year for Radiology done by a Radiologist or blood tests done by a Pathologist when all available day-to-day benefits have been depleted. The Radiology benefit includes sonars done by a Radiologist but excludes sonars done by a GP or Gynaecologist. |
|
Oncology treatment |
R100 000 per Insured per treatment cycle |
The co-payment or deductible that your medical aid charges you or approved treatment after the higher of your oncology limit or R200 000 has been reached, including co-payments on items such as biological medication, radiotherapy, and chemotherapy per treatment cycle. |
|
Shortfall on Consumables In-Hospital |
R6 000 per Insured |
Benefit equal to the cost of consumables not covered by the Medical Scheme for treatment received for an in-patient and/or out-patient treatment (as stated in the Defined event of the Policy Contract). Covers shortfalls on disposable items such as surgical gloves, bandages, and gauze. |
|
Casualty Benefit |
R12 500 per Policy |
The cost of emergency medical treatment or a surgical procedure performed in the hospital casualty unit, should such cost not be covered by the Medical Scheme. Emergency Triage Index applies. (Include: Orange and Red triage). “Emergency” means the sudden and unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or death. The determination of an Emergency will be done through diagnosis (through classification by the attending Medical Practitioner and / or the Casualty Unit) and not on symptoms presented. Emergency Triage Index applies (Orange and red triage). |
|
Trauma Counselling |
R10 000 per Policy |
This benefit covers counselling sessions with a registered counsellor or clinical psychologist that may be required after a serious or traumatic event. Insured must receive counselling within (1) one year of trauma incident. |
|
Specialist Consultations |
R500 / Claim |
Only the gap portion of the Specialist Consultation will be covered for visits up to a maximum of 2 claims per annum. Due to the lack of legislation governing what a specialist may charge for an out of hospital consultation, it has become necessary to provide a benefit where Cura assists the member with the Gap between the Specialist Consultation charged and the medical scheme rate. |
|
Dental procedures |
R7 500 per Policy |
The cost of emergency medical treatment or a surgical procedure due to accidental impact resulting in severe physical injury or due to cancer. Implants are not included as part of this benefit. |
|
Additional Care Cover |
R4 000 per Family per annum |
Covers stay at a registered sub-acute or step-down facility for rehabilitation treatment, including therapy provided by on-site therapists (Sub-limit per policy and once Medical Scheme benefit limits are depleted). Includes registered Sub-Acute facilities such as Step-down (where the member needs the level of care which he/she would receive in hospital but does not need to be hospitalised) or rehabilitation facilities when a member needs to be rehabilitated after surgery. |
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THE FOLLOWING BENEFITS ARE NOT SUBJECT TO THE ANNUAL AGGREGATE LIMIT OF R201 000 PER INSURED PER ANNUM |
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|
Premature Birth |
R2 500 per Policy |
This benefit will provide a lump sum amount in the event of a premature birth (Birth between 24 - 34 weeks of pregnancy) of the Principal Member or spouse. |
|
International Medical Travel Cover |
R5 million per Insured |
Maximum of 90 days per trip. Maximum age is 80 years at next birthday. |
|
12 Months Medical Scheme Premium Waiver |
Maximum R5 500 per month |
This benefit will cover the monthly premium due to your Medical Scheme in the event of the accidental death and permanent disability of the Principal Member as a result of an accident for a period of 12-months. |
|
Gap Premium Waiver |
6 Months |
This benefit will cover the monthly premium of your Gap Cover in the event of the accidental death and permanent disability of the Principal Member as a result of an accident for a period of 6-months. |
Waiting periods:
- 3-month general waiting period.
- 12-month waiting period for pre-existing conditions.
- 9-month waiting period on pregnancy.
Concessions on the above waiting period will be considered for group schemes.
Maximum Entry Age:
No maximum entry age is applicable to this policy.
Child dependants are covered until they reach the age of 21 years, with the option to continue cover as a principal insured and no new underwriting or waiting periods will apply. The age of 21 may be extended up to 26 years in respect of an unmarried child dependant who is a full-time student, provided proof thereof can be provided to Cura Administrators.
All new-borns must be registered on this policy within 30 days after birth.
Premium:
| Entry Age | Monthly Premium |
|---|---|
| Individual < 64 years | R480.00 per month |
| Family < 64 years | R565.00 per month |
| Individual > 65 years | R565.00 per month |
| Family > 65 years | R780.00 per month |
Premiums are paid monthly and are VAT inclusive. Premiums are reviewed and may be adjusted annually.
Terms and conditions apply in terms of exclusions and claim procedures.
