Sirago - Plus Gap Cover
Sirago’s Plus Gap Cover plan includes gap cover up to 500% for in-hospital claims, co-payment and penalty fee cover, out-patient surgical procedures, cancer cover, appliance benefit, sub-limit enhancer cover, out-patient specialist shortfall cover, preventative care cover and emergency room treatment, subject to available limits.
Gap Cover Benefits
| Co-payment benefit |
Subject to R191 000 per insured person per annum. CO-PAYMENTS subject to OAL. PENALTY FEES will be covered up to R9 500 per incident with a maximum of 1 (one) claim per annum for the voluntary use of a Hospital or Day Clinic outside your medical scheme's Designated Network. |
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| Dental benefit |
Specialized Dentistry is covered in hospital only |
| Diagnosis benefit |
Once-off payment of R17 000 when you are diagnosed with cancer for the first time. Only 1 claim per insured person per annum as defined. |
| Emergency/casualty benefit |
Provides cover when you visit the emergency room for accident and trauma / child emergency illness benefit for children 8 years and under. R1 000 Emergency illness benefit for persons 9+ years, subject to the sublimit. We will cover a GP if there no emergency hospital is available within a 30Km radius. Benefit is limited to R9 000 per policy per annum. Subject to R191 000 per beneficiary per annum. |
| Full time students over 21 |
Covered up to the age of 27 as long as they are full-time students (including if they are on their own option) – they do not have to be unmarried |
| Gap cover limits |
R191 000 overall limit (OAL) per insured person per annum. |
| Gap cover percentage benefit |
An additional 500% of what your medical scheme paid and limited to a maximum of 600% or at the stated benefit value with no limit on the number of times you may claim per year. This includes cover for doctor's, specialists, basic radiology, pathology, physiotherapy as well as PMB conditions. Robotic surgery limited to R18 000 per annum, R6 000 per claim with a max. 2 Claims per insured person per annum. |
| Lives Covered |
All dependants are covered under the principal member's medical aid. If membership split on more than two Medical Aids / options cover will be limited to family size i.e. 2 adults and unlimited children up to 21 and to age 27 if full time students |
| Maximum entry age |
There is no maximum entry age applicable |
| Oncology benefit |
The oncology co-payment benefit is applicable to the co-payment imposed by the medical aid once the oncology limit is reached. Subject to R191 000 per insured person per annum. In the event of the Medical Scheme approving reconstructive surgery on the affected breast, we will cover the Gap portion of 500% of the claim. In addition to this, Sirago will make available R20 000 (Stated Benefit) for the reconstruction of the non-affected breast, with supporting documentation |
| Oncology supplementary benefit |
Cancer Boost Benefit is subject to R191 000 per insured person per year. This can be claimed once your Rand limit on your Medical Scheme Oncology benefit has been reached and you need further treatment. In the event of the Medical Scheme approving reconstructive surgery on the affected breast, we will cover the Gap portion of 500% of the claim. In addition to this, Sirago will make available R20 000 (Stated Benefit) for the reconstruction of the non-affected breast, with supporting documentation. |
| PMB cover |
Voluntary use of non-DSP for PMB treatment is covered. Subject to the OAL *No cover for emergency or involuntary PMB treatment. |
| Sub-limit benefit |
R30 000 per policy per annum with a sub-limit of R11 500 per claim. The Sub-limit Enhancer benefits are limited to MRI / CT scans and Internal prosthesis. Subject to R191 000 (OAL) per insured person per annum |
| Trauma counselling |
R4 000 sub-limit per policy per annum. A stated benefit of R800 per claim You will be covered within the first 6 months after a traumatic event with a registered medical professional. This benefit covers you but not limited to; Dread Disease, Hijacking and or Violent Crimes at the discretion of the Insurer on the provision of supporting documentation Subject to R191 000 per insured person per annum. |
Gap Cover Contributions
| Contributions |
R395 for individuals (0 - 64) R452 for families (0 - 64) R615 for individuals (65+) R701 for families (65+) |
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