Gap Cover for Medical Expense Shortfall

Gap Cover

iWYZE Gap Cover is there for you when your medical scheme cover falls short. The main purpose of Gap Cover is to bridge the shortfall gap between what the medical scheme pays and what a Medical Practitioner charges.

Why do you need Gap cover?

iWYZE Gap Cover is there for you when your medical scheme cover falls short.

The Council for Medical Schemes recommends an annual medical scheme rate – this is the base rate that can be charged by all medical practitioners for medical procedures. Most medical schemes agree to pay up to a certain percentage of this rate – in most cases up to 100% of this rate. However, medical practitioners are free to charge whatever they want for their services, and should your provider charge more, it will be your responsibility to cover the shortfall.

For example: Let’s say your medical scheme covers up to 100% of the medical scheme rate. If a medical practitioner charges 500% of medical scheme rates, your medical scheme will cover the first 100% and you will have to pay the additional 400%. Medical practitioners may also request certain tests and procedures which would also require co-payments from your pocket.

Medical procedures are expensive, and this can mean an instant bill of tens of thousands of Rands, if not more. Gap Cover is important as an additional cover to buy with your medical scheme cover to cover shortfalls that may occur.

iWYZE Gap Cover is not a medical scheme and the cover is not the same as that of a medical scheme. This policy is not a substitute for medical scheme membership.

Healthy benefits to protect you against shortfalls

iWYZE Gap Cover offers excellent In-Hospital, In- and Out-of-Hospital Oncology and Out-of-Hospital benefits to cover defined medical expense shortfalls for tariffs, oncology, sub-limits, co-payments and deductibles, plus a Benefit Extender in addition to the core benefits.

iWYZE Gap Cover

Available to members of a registered medical scheme.
Pays up to five times (500%) the medical scheme rate if designated service providers are used.
Pays up to two times (200%) the medical scheme rate for Anaesthetist costs for all in-hospital procedures.
Pays up to one times (100%) the medical scheme rate for shortfalls on: 
- maxillofacial, back and spinal surgery and orthopaedic surgery OR for shortfalls where a non-designated service provider was used on a group network option and.
Cover applies to the member, spouse and children (up to 26 years of age).
With iWYZE Gap Cover you can have cover for up to 7 family members (on the same medical scheme)

Covered events

Hospitalisation for accidental harm, illness or other health incidents.
Oncology treatment, including chemotherapy, radiotherapy or other drug regimen approved by an Insured’s Medical Scheme.
Additional costs incurred as a result of childbirth in a Hospital ward.
Accidental harm resulting in emergency medical treatment at the out-patient casualty or trauma ward of a hospital.

Gap Cover benefits

In-hospital benefits

In-Hospital benefits include cover for tariff shortfalls, co-payments and deductibles and shortfalls from sub-limits arising from defined in-hospital consultations and procedures.

In- and out-of-hospital oncology benefits

In- and Out-of-Hospital Oncology benefits include cover for shortfalls on oncology treatment. These shortfalls can be significant and can occur as a tariff shortfalls, co-payments or sub-limits.

Out-of-hospital benefits

Out-of-Hospital Benefits provide cover on defined surgical procedures, treatments and medical expense for tariff shortfalls and co-payment and deductibles received as an out-patient. It also includes cover for accidental casualty and external appliance benefit.

Benefit extender

The Benefit Extender was designed to assist with additional benefits (over and above the core benefits) for certain medical events, resulting in additional non-medical expenses that will not be covered by your medical scheme. These benefits can be used at own discretion.

Maximum compensation for all gap cover benefits*

The total maximum Compensation Limit payable for all Core Benefits and Benefit Extender will be limited to R210 580 (two hundred and ten thousand five hundred and eighty rand) per insured person, per annum.

*Cover benefits, limits and maximum compensation limit applicable from 1 January 2025.

Terms & Conditions apply.

Important note

During the first 12 months of membership, a pre-existing condition waiting period applies.
During the first 3 months of membership, a general waiting period applies.
During the first 12 months of membership, a pregnancy waiting period applies.

Please note the 3 months general waiting period, 12 months pre-existing condition waiting period and 12 months pregnancy waiting period apply to an insured person from the time that such person's cover commences under the policy (to run concurrently if two or more waiting periods are applicable to an insured person).

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Disclaimer
This is not a Medical Scheme and the cover is not the same as that of a Medical Scheme. This Policy is not a substitute for Medical Scheme membership. Kaelo Risk (Pty) Ltd is an Authorised Financial Services Provider (FSP 36931). This product is underwritten by GENRIC Insurance Company Limited (FSP: 43638). GENRIC is an Authorised Financial Services Provider and licensed non-life Insurer.