Gap Cover Brochure. Version Essential Med Version Dated May 2015.

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Spencer Walton
8 years ago
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1 Gap Cover Brochure Version

What is Essential Gap? Essential Gap is an insurance product that protects medical aid members like you, by covering their medical aid scheme s payment shortfall during hospitalisation.

Most medical aid schemes cover hospital costs at 100% of the applicable medical aid rate.

2 What is Essential Gap? Essential Gap is an insurance product that protects medical aid members like you, by covering their medical aid scheme s payment shortfall during hospitalisation. We expect our medical aid to protect us from the potentially crippling costs of professional private healthcare when we are most vulnerable. However, this is not the case. Most medical aid schemes cover hospital costs at 100% of the applicable medical aid rate. However, most specialists, surgeons, anaesthetists and other healthcare professional service providers charge in excess of this recommended rate. Therefore medical aid scheme members are left with substantial shortfalls in payment for these services, which, depending on the severity of condition and length of stay in hospital, could significantly impact on a members financial wellbeing. Essential Gap will pay the difference between the medical aid scheme s payment and the actual private rate charged, up to seven times the medical aid rate with an unlimited annual limit. What about Co-payments? Your medical aid also imposes a co-payment fee if you choose to have certain procedures in hospital. Should you choose either the Essential Gap Superior or Exclusive plan with us, we will cover your co-payment for procedures performed in hospital up to R per annum. What is the difference between Co-payments and Sub-limits? A co-payment is a levy that your medical aid requires you to pay upfront before you are allowed to access certain benefits. A sub-limit is a limit within the amount of cover your medical aid provides, for a specific in-hospital event or procedure. This means that should the cost for a certain procedure exceed the applicable limit, you will be liable to pay the shortfall. Essential Gaps Exclusive option will provide you with the comfort of knowing that should your hospital sub-limit be exceeded, an additional R will be covered per annum. A 3 month general waiting period applies to the claiming of all benefits. However, a 12 month waiting period applies for maternity benefits. Ward fees, theatre fees, medicines and materials are, however, excluded from this benefit. 2

3 Premium Protect Premium Protect is an insurance product which has been designed to provide monthly funding for medical aid contributions in the event of the principal member passing away. The benefit of the Premium Protect is coverage of the medical aid contribution for any chosen cover period, 6 months, 12 months, etc. A waiting period of 6 months will apply. How to calculate your premium waiver contribution Amount of contribution cover required: ( A ) e.g. R4 000 Number of months cover required: 6 or 12 months ( B ) Total Rand amount cover required ( A ) X ( B ) = ( C ) R4 000 X 6 = R Monthly premium - R9 per R1 000 of cover required: R9 X ( C ): R9 X 24 = R216 per month. Monthly premium: R9 per R1000 of cover required: R9 x (C): R9 x 24 = R216 per month 3

4 Essences extras: R30 for two 2D movies at Nu Metro cinemas - Easy SMS code system & redeem your movie ticket, saving of R70! Save 10% on Intercape bus tickets 20% off on any Planet Fitness contract Discounts at Pick n Pay clinics Discounts with Reality partners as per Reality website ( Home assist: This helpline offers assistance with household emergency repairs, anywhere in South Africa. It covers the cost of 3 incidents per annum, limited to R500 per incident. Electrical, Plumbing, Locksmith Glazier, Domestic appliances Auto assist: Legal assist: Just call to get guidance and advice on legal matters from qualified and experienced attorneys. General legal advice, Labour law advice Motor accident advice Road accident fund advice Attorney referral service Std legal documentation Emergency Medical Evacuation: A single call from you (or a 3rd party) to our emergency number results in immediate action. Emergency vehicles dispatched immediately (cost covered) Telephonic advice to the primary accident scene attendant to assist in stabilising the patient In the event of a roadside emergency within South Africa, call this helpline for access to appropriate services. Cost of towing (to an approved dealer), Flat battery (jump start) Flat tyre (tyre change) Running out of fuel (10L of fuel supplied) Keys locked in car (locksmith) and In case of a breakdown 100km or more from home, accommodation or rental of a vehicle (maximum R500 per day) Funeral assist: For assistance with the facilitation of a burial. Advising and referral to a reputable undertaker, Help with funeral arrangements Advice on death certificate and legal documentation, Counseling of the bereaved. Health assist: Personal health advice from experienced professionals just a call away. Informing your next-of-kin about your accident Emergency medical advice, Symptom assessment, General health information, Counseling on HIV/Aids, cancer, addiction, stress and trauma Travel assist: Just call for info, availability and costs of national and international accommodation, transport and special packages. Call and get directions when travelling anywhere is South Africa. Directions are given telephonically, via or fax. Available 24/7 on * terms and conditions apply visit 7 4

5 To upgrade or not upgrade your medical aid? Try Essential Gap Cover. For as little as R140 per month you can close the gap between what your medical aid pays and what private healthcare providers charge for services. Considering that this small monthly premium can save you from a cost amounting to much more than R8000, it makes our choice on whether to upgrade our medical aid or not, much easier. Examples of cover provided: Procedure Cost Medical Aid pay out Shortfall Gap Claim Tonsillectomy R12, R4, R8, R8, Appendicectomy R3, R1, R2, R2, Hysterectomy R12, R4, R8, R8, For a small monthly premium you can ensure that you are protected from the unwelcome surprises of unexpected in-hospital costs that your medical aid doesn't cover. Essential Gap cover offers four price options: Product Elite Prestige Superior Exclusive Gap cover percentage 500% 600% 700% 700% Gap cover annual limit R Unlimited Unlimited Unlimited Co-payment cover None None R per policy per annum R per policy per annum Sub limit cover None None None R per event. R per policy per Monthly premium annum. Main member only R140 R160 R185 R215 Main member plus family R140 R160 R185 R280 NB: Elite, Prestige and Superior premium covers all members on the medical aid. We take care of medical costs, you take care of life. 5

6 ESS MED MEDICAL COVER (Pty) Ltd Trading as Essential Gap Registration number: 2000/017936/06 Essential Gap is a registered financial services provider. FSP Essential Group Building, Olive Grove Estate, Ou Paardevlei Road, Somerset West, 7130 PO Box 653, Somerset Mall, 7137, Tel: , Fax: , info@essentialgap.co.za, Website: 6

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