Better Cover. Better Value.

A registered Financial Service Provider (FSP 45834).

Gap Cover

Due to the extra costs that you or your family often have to pay to doctors and specialists for most in and out of hospital procedures, a very affordable medical gap cover has been developed exclusively for government employees. This gap cover can save you thousands of rands for in and out of hospital procedures that are needed by you, your spouse or children. Most operations such as childbirth, gynaecological and heart procedures often mean that you have to pay in thousands of rands extra that the medical aid might not cover.

This affordable medical gap cover will now provide you with cover on these shortfalls of up to two times (2X) of the medical aid rate. This product is underwritten by Guardrisk Insurance Company Ltd an Authorised Financial Services Provider and brought to you by Africa Direct, an Authorised Financial Services Provider.

WHAT ARE YOU COVERED FOR?

Benefit for shortfalls in medical practitioner costs on Africa Direct Superior Gap

MAIN GAP BENEFITS

Click on tabs below for more info.

SHORT FALL COVER

Shortfalls on Medical practitioner costs up to the overall annual limit of R150 000.

CO-PAYMENT

Co-payments levied by the scheme for admissions to DSP service providers and MRI/Cat scans (subject to overall annual limit of R150 000)

ACCIDENTAL INJURY ONCOLOGY CO-PAYMENT / EXTENDER

Oncology co-payments up to 20% levied by the medical aid (subject to the overall annual limit if R150 000)

SHORTFALL FOR INTERNAL PROSTHESIS

Up to R30 000, but subject to the overall annual limit

CASUALTY BENEFIT

Up to R5000 of the costs paid by you for accidental emergency treatment (one casualty visit per policy per year)

LUMP SUM CANCER

R15 000 once off lump sum for first time cancer diagnosis. A further R10 000 payout if the schemes annual limit is reached in the same policy year)

LUMP SUM ACCIDENTAL DEATH / DISABILITY

R50 000 lump sum for accidental death or permanent disability. Only paid once per insured in a lifetime.

FIXED DENTAL

Up to R10 000 (R2 000 per tooth x 5) for emergency tooth repair due to an accident


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IN-HOSPITAL PROCEDURES

The maximum amount that we will pay towards this shortfall is calculated at 2 times (or 200% of) the medical aid tariff defined by your medical aid, less the amount payable or actually paid by your medical aid, or 1 times the medical aid tariff, whichever is the higher.

In most instances the medical practitioner will separate the primary procedure that they have performed into a number of smaller procedures on the account that they issue for payment. This is because they are required to detail every “sub-procedure” undertaken during your primary procedure for medical aid billing purposes. If the medical practitioner does this, we will also separate the shortfall for each sub-procedure in our calculation of the amount owing to you.

This means that we may pay the full shortfall on some sub-procedures, a portion of the shortfall on other sub-procedures (for example where a sub-limit has been reached) or no portion of the shortfall on certain sub-procedures (for example, whether your medical aid has not paid the first portion of a specific sub-procedure).

We will provide you with detail regarding how we have calculated the amount that we will pay you for each sub-procedure if you ask us to do so.

It is important for you to be aware that under this benefit we will only cover you for any shortfall if the procedure took place while you were admitted to, and staying in, hospital.

OUT-OF-HOSPITAL PROCEDURES

If, after the expiry of any waiting period applied to your cover, you undergo a procedure to treat a disease or a bodily injury and this procedure is listed below and is performed by a medical practitioner outside of a hospital (in other words, on an outpatient basis in a registered day clinic), we will cover you for the shortfall between what the medical practitioner has charged you and what your medical aid has paid for the procedure.

Once again the maximum amount that we will pay towards this shortfall is calculated at 2 times (or 200% of) the medical aid tariff defined by your medical aid, less the amount payable or actually paid by your medical aid, or 1 times the medical aid tariff, whichever is the higher.

In addition, if the medical practitioner separates the primary procedure that they have performed into a number of smaller procedures on the account that they issue for payment, we will also separate the shortfall for each sub-procedure in our calculation of the amount owing to you.

HOW TO CLAIM

Claim forms are obtainable from our Customer Care department on customercare@africadirectlife.co.za or by contacting our customer care department on Tel: 0861 91 91 91.

Please Note: All related documents must be submitted with the completed claim form within six months of your hospitalisation or procedure.

Claim forms can be submitted by emailing to: claims@africadirectlife.co.za or posting to Africa Direct Life and Investments | PO Box 2511 | Clareinch | 7740 as soon as possible.

General & Claim Enquiries:

Tel: 0861 91 91 91 | Email: customercare@africadirectlife.co.za

Call us – 0861 91 91 91. Email us – customercare@africadirectlife.co.za

About Us

Africa Direct Life and Investments (Pty) Ltd is a registered Financial Service Provider (FSP 45834). We are a specialized product development and Financial services provider house with over 20 years’ experience in the Financial Services sector.

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