Zestlife - Universal Gap Cover

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 R165 000 per insured person per annum. 1 Co-payment up to an amount of R10 000 per policy per year for the voluntary use of a Hospital or Day Clinic outside your medical scheme's Designated Network.

Dental benefit

R19 250 Accidental tooth fracture cover is provided per person per year. Limited to R2 750 per tooth, irrespective of cover provided by your medical scheme. The removal of Impacted Wisdom Teeth is only covered if performed in Hospital. Dental Implants are not covered. All in-hospital specialist shortfalls for medical scheme approved dental procedures are also covered

Diagnosis benefit

Once-off payment of R30 000 per beneficiary when you are diagnosed with stage 2 cancer for the first time 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

Limited to R20 000 per policy per year and subject to R165 000 per insured person per annum. The visit must have taken place within 48 hours of incident.

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 R30 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 R165 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 R20 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 R25 000 per policy per year with a sub-limit of R750 per counselling session and subject to R165 000 per insured person per annum

Gap Cover Contributions

Contributions

R401 for individuals (55<)


R506 for individuals (55 - 64)


R568 for individuals (65+)


R506 for families (65<)


R568 for families (65+)

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