Zestlife - Universal Gap Cover
Zestlife's Universal Gap Cover option provides comprehensive gap cover. It includes a more generous range of benefits than the Essential option, for only a small difference in premium.
Along with medical expense shortfall cover for in-hospital expenses, it includes gap cover for specific out-of-hospital procedures; emergency room/casualty ward cover; and a range of health insurance benefits.
Among other benefits, it also includes non-network copayment cover, enhanced cancer cover and shortfall cover for in-hospital dentristy.
Gap Cover Benefits
| Co-payment benefit |
All co-payments subject to R192 000 per insured person per annum. 1 Co-payment up to an amount of R11 600 per policy per year for the voluntary use of a hospital or Day Clinic outside your medical scheme's Designated Network. |
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| Dental benefit |
All in-hospital specialist shortfalls and co-payments, for medical scheme approved dental procedures (including removal of impacted wisdom teeth), are covered. Dental implants and other material are not covered. R22 500 Accidental tooth fracture cover is provided per person per year. Limited to R3 200 per tooth, irrespective of cover provided by your medical scheme |
| Diagnosis benefit |
Once-off payment of R30 000 per beneficiary when you are diagnosed with stage 2 cancer or stage 1 prostate cancer where the Gleason score is 8 or higher and Oncology treatment is required. Standard 12 month waiting period is applicable from start date of policy. This benefit can be increased to a total amount of R100 000 or R200 000 for an additional premium. |
| Emergency/casualty benefit |
Injury treatment due to an accident limited to R22 100 per policy per year and subject to R192 000 per insured person per annum. Emergency treatment of up to R2 500 per policy per year for children younger than 11. Please refer to product brochure / policy schedule for terms & conditions. When immediate treatment is required as a result of an emergency and your Medical Scheme does not provide you with cover and you become liable to pay the cost of the casualty event |
| Full time students over 21 |
Covered, as long as they are dependants on your medical scheme. |
| Gap cover limits |
R165 000 overall limit per insured person per year. |
| Gap cover percentage benefit |
Shortfall calculated as amount charged by provider (limited to 500% of med aid tariff) less the higher of the medical aid tariff or the amount paid/payable by the medical aid. This includes cover for doctor's, specialists as well as PMB conditions. Cover of up to R33 000 per policy per calendar year for medical expense shortfalls that arise directly from the use of robotic machinery in the course of in-hospital operative treatment. |
| Lives Covered |
Main member & Spouse, even if they are not on the same medical scheme; All dependants registered on Main member's or Spouse's medical scheme; Individuals of all ages. |
| Maximum entry age |
There is no maximum entry age applicable. |
| Oncology benefit |
Up to an aggregate of R192 000 per insured person per annum and is applicable to the co-payment specified by the medical scheme for Oncology treatment including chemo / radiotherapy and once Oncology treatment limit has been reached. Cover is subject to a maximum co-payment of 25% in any one claim. Up to R24 000 cover for surgical costs not covered by your medical scheme for breast reconstruction of the non-affected breast in the event of a single mastectomy resulting from cancer. |
| Oncology supplementary benefit |
Where a cancer treatment cost limit is imposed and where no further treatment is funded by the medical aid, this benefit will subsidise 20% of the ongoing treatment costs. This benefit can be used to cover general treatment and the costs of biological drugs and other specialised treatments. |
| PMB cover |
Prescribed Minimum Benefits are covered. |
| Sub-limit benefit |
Cover of up to R35 000 per policy per year for cover shortfalls on the cost of Internal Prosthesis. Intra Ocular lenses are excluded. Subject to R165 000 per insured person per annum. Once a medical aid sublimit has been reached, we will still cover the difference between what the specialists charged and what the medical aid would have paid. Client liable for Hospital Bill and what the medical aid would have paid. Subject to the R165 000 per insured person per annum. |
| Trauma counselling |
Covers consultation fees up to R26 500 per policy per year with a sub-limit of R800 per counselling session and subject to R192 000 per insured person per annum. |
Gap Cover Contributions
| Contributions |
R478 for individuals (35<) R478 for individuals (55<) R606 for individuals (55 - 64) R710 for individuals (65+) R606 for families (65<) R710 for families (65+) |
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