Medical Gap Cover FAQs Download as PDF

• Who is covered by this policy?

  Cover is provided for you and your family members that are specifically listed as either your spouse, children or extended dependent with your medical scheme.

• What is the Personal Accident Benefit?

  This benefit is included at NO EXTRA cost.

  Only the Principal Member is covered for a maximum amount of R25000 if he/she is disabled as a result of an accident. The amount of the benefit may vary depending on the severity of the injury/disability. The benefit also includes various emergency services like Emergency Transportation, Trauma counselling and life support equipment.

• Do I need to remain a member of a medical scheme to qualify for Gap cover?

  Yes, you can only enjoy cover under this policy for as long as you remain a principal member or dependant of a registered medical scheme.

• Do I need to provide details of the dependants on my medical scheme and changes to dependants?

  No, at the time of the claim, confirmation will be required to prove that they were dependants of your medical scheme.

• What is an extended dependant?

  An extended dependant is either a parent or sibling of the Principal Insured's that is registered as their extended adult dependant.

• Does the policy cover more than one eligible spouse?

  If you have more than one eligible spouse/partner, then you must nominate the spouse/partner that will be covered. If you do not nominate a spouse/partner, then not one of the spouses/partners will be covered.

• What happens if as the principal insure, I pass away before my spouse?

  Your spouse could still continue the cover should they elect to do so provided they inform us in writing within 60 days.

• Is Medical Gap Cover only valid on a specific medical scheme?

  No, this policy can be used on any registered medical scheme.

• What exclusions exist in the Medical Gap Cover?

  The list of exclusions include the standard insurance exclusions such as sickness or injury that is caused from nuclear weapons or material, injury from an accident while over the legal alcohol limit, active participation in war, police duty, civil commotion. Then there are a number of specific exclusions such as cosmetic surgery and treatment for obesity and any event not covered by your medical scheme. It is however worth studying the full list of exclusions which appears in the policy document.

• What waiting periods exist in the policy?

  Waiting periods that are applicable:
  a) Birth related claims - 10 months.
  b) First 6 months 0% benefit and 50% of the normal Medical Gap Cover benefit in the second
      6 months for:

  1. Joint replacements (except as a result of an accident/injury occurring after joining),
  2. Arthroscopic procedures (except as a result of an accident/injury occurring after joining),
  3. Spinal surgery including spinal fusion (except as a result of an accident/injury occurring after joining),
  4. Nasal surgery including sinus related (except as a result of an accident/injury occurring after joining),
  5. Cataract surgery,
  6. Hysterectomy (except for cancer diagnosed after joining),
  7. Dentistry related claims (except reconstructive as a result of an accident/injury occurring after joining),
  8. All hernia repairs (except as a result of an accident/injury occurring after joining), and
  9. All cardiac related surgery and procedures (including angioplasty and cardiac catheterization) diagnosed prior to date of joining.

• What happens if the Medical Schemes Council ceases to permit the sale of Medical Gap Cover?

  Under the current legislation this cannot take place as the Constitutional Court has ruled in favour of its legality. Should the legislation, however unlikely, ever be changed, leading to Gap Cover being deemed unpermissible it is the opinion of the insurer that all existing policies would be allowed to continue and it would only be the taking on of new policyholders that would be curtailed. This is an unlikely event as the courts have already ruled that this is a permissible insurance product that does not perform the function of a medical scheme.

• Which Insurer underwrites this policy?

  The policy is underwritten by Guardrisk Insurance Company Limited, which is a wholly owned subsidiary of Alexander Forbes one of South Africa's leading financial service companies in South Africa.

• Will I be required to go for a medical examination to qualify for the policy?

  There are no medicals required when applying for this policy and cover is immediately available.

• Does this policy have a surrender value under?

  There is no savings or endowment portion and there is therefore no surrender value of the policy.

• Will my premium increase each year?

  Yes. The premium amount will be reviewed on 1 February each year and you will be notified of any premium increase on 1 (one) months' notice.

• Is there a policy fee attached to this policy?

  There is absolutely no additional policy fee, the costs incurred for administration is covered in your premium.

• When will premium payments commence?

  The first premium will be debited on a day of your choice.

• When will I start enjoying the cover under the policy, i.e. when will the policy commence?

  Cover will commence on the 1st day of the month for which your first premium is collected.

• I only want to commence cover under this policy in the future, what is the maximum lead period that can be catered for?

  A first debit order date 3 calendar months hence.

• When will I receive my policy documents?

  Your policy documents will be sent to you by email once you have taken out this cover. You will also be able to view the policy in myinstantlife.co.za

• When does the policy terminate?

  There is no specific age limit that gives rise to this policy terminating however if the policyholder allows the policy to lapse or when the policyholder cancels the policy it will terminate.

• What is the oldest age that an individual can apply for the cover?

  There is no maximum entry age for the Medical Gap Cover.

• Can my application be declined?

  Cover is guaranteed and no applications will be declined provided that you are a member of a medical aid.

• Can I recommend this policy to a friend or relative and how can they get hold of you?

  Yes, please refer them to the instantlife.co.za website. Thank you for this referral.

• How do I submit a claim?

  Within 6 months of a hospital admission giving rise to a claim you need to submit a claim. This can be done by contacting 0860 102 936 or admed@guardrisk.co.za

  You are however encouraged to submit a claim as soon as possible.

• What are the documents that I need to submit with a Medical Gap Cover claim?

  The completed claim form and copies of your hospital account, doctor's account and your medical aid statement. If the claim was due to an accident that occurred during the waiting period you will also have to submit a letter giving details of the accident as well as a doctor's reports providing details of the accident and related implications.

• To whom is the benefit paid to?

  The benefit is paid directly to you and you are responsible for settling the accounts with the doctor.

• How long does it take to pay a claim?

  Approximately 25 working days from receipt of a completed claim form and all required documentation.

• What does Admed cover?

  AdmedGap is the short term insurance policy that covers the difference between what the doctors (e.g. anaesthetist, surgeons, other specialists and GP's) have charged while in hospital and the applicable Admed-tariff for the service/s rendered.(limited to a maximum of 4 times the Admed-tariff).

• What is "Admed Tariff"?

  This is the tariff table published by Guardrisk Insurance Company Limited made up of procedure codes as previously published by the Council for Medical Schemes and appropriate tariffs as determined by Guardrisk Insurance Company Limited for each procedure code.

• What does RPL (Reference Price Listing) stand for?

  This is the guideline price published by the Department of Health for all medical services. Your doctor may or may not charge according to the price listing. According to the Competition's Commission, he is not bound by this price listing.

• When does Admed apply?

  Only for claims incurred while you are Hospitalised (operation, accident, illness etc) and for certain procedures performed on an out-patient basis (day-to-day services) at a doctor's surgery like a gastroscopy, colonoscopy, removal of cataracts and certain biopsies.

• What are day-to-day services?

  Day-to-Day services are all medical services where the member is not hospitalised. This will include your spectacles, medication, doctors' visits, specialist visits etc. – such services are not covered under the Admed policy.

• How much does it cost?

  R128 per month, irrespective of the size of your family.

• Who can join Admed?

  Any member belonging to a defined group contracted to Admed and who is registered as a principal member or a dependant on a medical aid scheme.

• Is there any age restriction upon joining the policy?

  No, there is no age restriction.

• Is the Admed policy available to individual members?

  No, Admed is currently only available to member's belonging to a defined group.

• How do you join Admed?

  By completing the Admed Application Form and returning it to your Human Resource Department or to Guardrisk Insurance Company Limited.

• What proof of membership do you receive as a member?

  All members who join Admed will receive a Membership Certificate (indicating a unique member number) and a Policy Document.

• How and when do members claim from Admed?

  Members have 6 months from the date of admission to hospital or other qualifying event, to notify Guardrisk in writing, of the claim. Members are however encouraged to submit a claim as soon as possible after the event. Members can obtain claim forms directly from Guardrisk.

• How is the benefit paid?

  Claim payments under the Admed insurance policy are deposited directly into the member's bank account.

• How long does it take to pay a claim?

  Approximately ten working days after receipt of all claim documentation.

• What documents do I need to submit when loding a claim?

  Completed Admed claim form and all supporting documents e.g. hospital account, medical practitioner's accounts and medical aid statement.

• Can you still claim if you have given notice to leave the Admed policy?

  Yes, you are still covered until the last day of your notice period and given that your contributions are paid up. Claims after that date will not be processed.

• What does Admed not cover?

  Admed does have exclusions, which have been highlighted below.

  No benefit is payable for hospitalisation directly or indirectly caused by or in consequence of:

  • Any claim not covered by your medical scheme
  • Attempted suicide or intentional self-injury
  • Any form of race or speed test (other than on foot or involving any non - mechanically propelled vehicle, vessel, craft or aircraft)
  • Being under the influence of alcohol, drugs or narcotics
  • Exposure to nuclear weapons, material or waste
  • Routine physical or procedure of a purely diagnostic nature
  • Investigative treatment for obesity and its sequelae, or cosmetic surgery
  • Depression, insanity, mental or mental stress conditions
  • Participation in military or police duty, criminal activity, riot or aviation (other than as a fare paying passenger)
  • Home and private nursing

• What are the types of waiting periods the policy can give you?

  Waiting periods are applicable to voluntary membership groups.

  • Birth related claims: 10 months from date of commencement
  • First 6 months of cover: 0% benefit • second 6 months of cover : 50% benefit for:
    
    • Joint replacements (except as a result of an accident/injury occurring after joining)
    • Arthroscopic procedures (except as a result of an accident/ injury occurring after joining)
    • Spinal surgery including spinal fusion (except as a result of an accident/injury occurring after joining)
    • Nasal surgery including sinus related (except as a result of an accident/injury occurring after joining)
    • Cataract surgery
    • Hysterectomy (except for cancer diagnosed after joining)
    • Dentistry related claims (except reconstructive as a result of an accident/injury occurring after joining)
    • All hernia repairs (except as a result of an accident/injury occurring after joining) and
    • All cardiac related surgery and procedures (including angioplasty, cardiac catheterization etc.) diagnosed prior to date of joining.

• Are there any instances where a waiting period will not apply?

  Waiting period will not apply on a compulsory membership and where the member has effected a continuation option.

• What does a waiting period mean?

  Period during which a member has to pay his normal monthly contribution but is not entitled to claim any benefits from the policy.

• Who qualifies as a dependant?

  A Child, including legally adopted child or stepchild of a Principal Insured Person and who is registered as their dependant on a medical aid scheme.

  • The Spouse, of a Principal Insured Person and who is registered as their dependant on a medical aid scheme.
  • A Parent or Sibling of a Principal Insured Person and who is registered as their dependant on a medical aid scheme.

• Can Guardrisk terminate my Admed membership?

  Yes, on non-payment of premiums.

• Am I covered under the Admed policy if I resign from my current employer?

  No, unless you elect to continue privately or you join another defined group that is participating on the policy and there's no break in membership.

• How would Admed be informed of my resignation from a defined group?

  The onus is upon the member to inform Guardrisk of any change in membership e.g. resignations, continuations, change of contact details etc.

• Is the continuation option available to Admed principal members?

  Yes, a continuation option is available to all Admed principal members should the member, retire, resign, or become a beneficiary of a disability pension.

• Must I give notice to the policy administrator if I want to terminate my Admed membership?

  Yes, we require a calendar month's written notice of your intention to leave the policy

• How is the premium collected?

  Through a debit order facility

• Is Admed a registered policy?

  Admed is a registered short-term Insurance Health and Accident policy.

• Is the policy only available or limited to certian medical schemes?

  No, the policy is available to any member belonging to a registered medical aid scheme.

• If a member dies, will his registered dependants still be covered?

  Yes, without any break in membership and provided contributions are paid. It is important to inform the policy administrator if one chooses not to continue.

• Is Admed a continuous policy or do I have to apply every year?

  Admed membership automatically rolls-over to the new policy period, unless the member elects not to continue with his/her membership.

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