Overall Annual Limit
The overall annual limit is R177 800 per insured person.
Tariff Shortfalls
Enhancing your medical scheme’s reimbursement rate for in-patient and/or out-patient procedures [as defined] by an additional 500% of the scheme rate. Subject to the overall annual limit.
Co-Payments/Deductibles
Where medical schemes have specified co-payments or deductibles applied to listed procedures that the member is required to pay, Proper Gap Comprehensive will reimburse the defined amount whether stated as a fixed Rand amount or percentage. Subject to the overall annual limit.
Sub-Limits
Medical Scheme options often place limits on certain procedures/events, e.g. internal prostheses, MRI/CT scan etc. Proper Gap Comprehensive will enhance your cover for defined sub-limits. Subject to the overall annual limit.
Casualty Benefit
In the event of accidental, trauma-related or crime-related injuries which culminate in treatment received within 24 hours of the event in a Hospital Out-Patients/Casualty Unit/Registered Medical Facility by an insured member, Proper Gap Comprehensive will provide an annual limit of R10 000 per family, further limited to R3 500 per event. Illness related emergencies will also be covered for infants and children under the age of 8 and illness related emergencies for members 8 years and over between 8pm and 6am.
Cancer Treatment
Most medical schemes place limits on their payment of cancer treatment such as Chemotherapy, Radiation & Cancer Biological drugs. Proper Gap Comprehensive will enhance this limit whether stated as a fixed co-payment or sublimit in accordance with the scheme’s limitations. Subject to the overall annual limit.
Specialised Dentistry
Cover for root canal and teeth extractions [excluding consultations] in dentists’ rooms to a maximum of R3 000 per person per event. This cover is extended to teeth extractions performed in hospital, including wisdom teeth. This is limited to clients whose medical schemes do not cover in-hospital dentistry or list it as a procedural exclusion. Limited to a combined overall annual limit of R6 000 per annum per policy.
Specialised Radiology Benefit
Proper Gap Comprehensive offers MRI/CT scan cover for clients whose medical schemes options exclude specialised scans. Limited to R5 000 per event and 2 claim events per policy per annum.
Out of Hospital Specialist Benefit
We will cover the difference in cost between what your specialist charges for a consultation in their private rooms and the rate your medical scheme applies to out-patient specialist consultation fees. Limited to R5 500 per policy, R1 500 per consultation and a maximum of 3 consultations (add – per) person per year. Your medical aid must pay a portion of your specialist’s consultation fee from a hospital, risk, day-to-day benefit or from your medical savings account.
