Sirago - Plus Gap Cover

Sirago - Plus Gap Cover

Sirago’s Plus Gap Cover plan includes gap cover for in-hospital claims, out-patient procedures and PMB treatments at non-DSP facilities, as well as ER cover up to an overall annual limit per policy per year.

Gap Cover Benefits

Co-payment benefit

Benefit covers all procedural co-payments as well as admission on penalty fees imposed by the medical scheme rules, subject to OAL. Percentage co-payment limit of R13,000 per claim. Penalty per cover has an incident limit per claim of R6,500 limited to 2 claims pppa

Dental benefit

In-hospital dental: gap and co-payments, subj to OAL. This benefit is not limited to impacted wisdom teeth

Diagnosis benefit

Once-off payment of R14,000 for first time cancer diagnosis

Emergency/casualty benefit

Overall sub-limit of R7,000 per policy per year. R35,000 for accidents and trauma related incidents, limited to R600 per claim

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

An Overall Annual Limit (OAL) of R164,000 per beneficiary, for in- and out-of-Hospital surgical procedures

Gap cover percentage benefit

Cover for up to 500% of the medical scheme tariff. Limited to a max of 600% or at stated benefit value, for hospital admissions; doctors, specialists, basic radiology, pathology, physiotherapy. Procedures performed as an outpatient basis are also covered (see list of procedures in policy document)

Lives Covered

Main medical scheme member; All family members registered as medical scheme dependants OR no more than 2 Adults and 3 Child dependants on different medical schemes

Maximum entry age

There is no maximum entry age applicable

Oncology benefit

A R50,000 per policy applies once your medical scheme oncology benefit limit has been reached and a percentage co-payment is applied. Limited to R60,000 per claim. Breast reconstruction is paid up to 200% of the gap portion and R16,000 (Stated benefit) for the reconstruction of the non-affected breast.

Oncology supplementary benefit

A R50,000 per beneficiary and subj to OAL is applied when medical scheme oncology benefit is reached and you require further treatment. Breast reconstruction is paid up to 300% of the gap portion and R16,000 (Stated benefit) for the reconstruction of the non-affected breast

PMB cover

Prescribed Minimum Benefits are covered

Voluntary use of non-DSP for PMB treatment is covered.

*No cover for emergency or involuntary PMB treatment

Sub-limit benefit

Enhancer benefit limit of R36,000 pfpa; with a sub-limit of R12,000 per incident, subject to 2 claims per policy and OAL

Trauma counselling

Limit of R3,000 pppa. Limited to a stated benefit of R600 per claim. Covers, but not limited to; Dread Disease, Hijacking and or Violent Crimes

Gap Cover Contributions

Contributions

Single 0 - 54yrs

R 324


Single 55 - 64yrs

R 400


Single 65yrs+

R 475


Family 0 - 54yrs

R 370


Family 55 - 64yrs

R 457


Family 65yrs+

R 543

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