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Sirago – Gap Assist Cover

In-Hospital Benefits

Gap Cover
Will settle claims above Medical Scheme rate or at the stated benefit value
Up to 500%
Excesses imposed by your medical scheme payable to a maximum rand limit for specified procedures or tests.
Cover for co-payments imposed by medical schemes for hospital admissions, scans and surgical procedures.
Co-payments related to cancer are catered for in a separate benefit category.
Subject to a sub-limit of R42 000 per policy per annum
Limited to R11 000 per claim
Day Hospital/Clinic and/or In Room Surgical Procedures Cover
Will settle the GAP portion of claims
PMB Cover
This benefit will cover the shortfall resulting from the use of a non-designated service provider for planned procedures except in the event of an emergency
Limited to R30 000 per claim.
Subject to OAL.
Hospital Account Shortfalls
Subject to a sub-limit of R2 000 per policy per annum
Maximum of R500 per claim
Maximum 3 claims per beneficiary

Out-of-hospital benefits

Emergency Room Cover
This benefit covers an emergency at any Registered Emergency Facility when you require immediate medical treatment due to an accident or illness.
The following benefits collectively accumulate to the sub-limit.
Accident benefit: all costs related to the accidental event will be covered and paid to a maximum value of the sub-limit available, whether you are liable to pay the costs related to the emergency event out of your own pocket or if your medical scheme pays from your savings account.
Illness benefit: when you visit an emergency room in a medical emergency as a result of illness, we will cover the Gap portion only if the medical scheme has paid a portion.
We will cover a GP’s emergency facility where no hospital emergency is available within a 30km radius within the above stated benefit limits.
A sub-limit of R4 500 is applicable
Appliance Benefit
For your Gap component as per the defined list; hearing aids, wheelchairs, CPAP machine, humidifiers, insulin pump, glucometer, nebuliser and the Mirena device.
Maximum claim amount R3 600 per policy per annum
Claim limit of R1 200

Cancer Benefits

Cancer Co-payment Benefit
Once your medical scheme cancer benefit has been reached and a percentage co-payment is imposed. This benefit incorporates co-payments, and co-payments related to biological drugs. In order to access this benefit, you need to be on a registered treatment plan with your medical scheme
Limited to R100 000 per policy
Limited to R15 000 per claim
Cancer Benefit – Boost
This benefit is restricted to policyholders where their medical scheme option has a defined rand limit for cancer treatment.
The Cancer Boost benefit can only be claimed once your rand limit on your medical scheme cancer benefit has been reached and you require ongoing treatment.
This benefit is dependent upon the insured having already been registered on the medical scheme’s cancer programme.
The Cancer Boost benefits are limited to those that were determined within the approved medical scheme treatment plan which must be submitted to Sirago upon application for this benefit.
This benefit provides a subsidy towards the cost of ongoing treatments and drugs.
This applies when the medical scheme’s cancer benefit limit is reached and provides no further funding.
Limited to R50 000 per beneficiary per annum

Value Added Benefits

Gap Cover Premium Waiver
In event of death or total permanent disability of the policyholder of the Sirago policy.
The Premium Waiver is directly linked to your policy premium per month as indicated in your schedule of insurance.
This benefit is not paid in cash, but held as a credit against the policy for the applicable 6 month period.
Should there be any premium adjustments within the 6 month period, the credit balance available for the rest of the waiver period, will be adjusted accordingly.
This benefit cannot be transferred, ceded or converted to cash
Sira-Go’ Baby
An instruction to add a new-born to the policy must be submitted within 31 days of the birth of the child.
After confirmation of pregnancy, this benefit is for claims for prenatal scans, childhood immunisations or pre-and post-birth tests (to limit) per child.
In the event of twins, the benefit will be doubled, and in the event of triplets, the benefit will be tripled
Sublimit of R2 000