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Sirago – Gov-Gap Cover

What is Gov-Gap Cover

This policy has an Overall Annual Limit (OAL) of R176000 per beneficiary.
This product is a tailor made solution for Government employees who need to optimise their healthcare cover portfolio and premiums covered by Persal.
Membership Eligibility
Principal policyholders must be in the fulltime employment of The State and be in possession of a valid and current Persal number in order for a Gov-Gap policy documents to be issued.
Gov-Gap has a policy cease age of 65.
The policy will cease at the end of the benefit year when the policyholder turns 65.

In-Hospital Benefits

Gap Cover
Gap Cover will settle claims up to 500% above your medical scheme plan/option rate, to a maximum of 600% or at the scheme stated benefit value as determined within your scheme policy.
Up to 500% above Medical Scheme rate
The 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.
Sub-limit of R40 000 per policy per annum
Limited to R5 500 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 your Gap portion for the voluntary 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 R5 000 sub-limit per policy per annum.
R1 250 per claim.
Maximum 2 claims per beneficiary per annum.
Sub-limit Enhancer
The sub-limit enhancer benefits are limited to internal prosthesis, intraocular lenses, MRI scans and CT scans only.
Sub-limit of R45 000 per policy per annum.
Subject to R15 000 per claim.
Maximum of 2 claims per beneficiary
Limited to 3 claims per policy per annum

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.
Sub-limit of R7 500 is applicable
Day-to-day Specialist Consultation Fee
For the Gap portion only.
Sub-limit of R3 600 per policy.
Maximum of R850 per claim.
Maximum 2 claims per beneficiary per annum

Cancer Benefits

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 R100 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 12 month period.
Should there be any premium adjustments within the 12 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
Medical Scheme Premium Waiver
Payable in event of death or total permanent disability of the principal policyholder of the Sirago Gap Cover.
In the event of dual medical scheme membership, this benefit is only payable in event of death or total permanent disability of the principal policyholder.
Sirago will pay the medical scheme premium to the actual amount of the contribution, but not higher than the sub-limit per month for a 4 month period which, will be paid to the beneficiary for the upkeep of their medical scheme contributions.
In order to receive the benefit, the Gap Cover policy and medical scheme membership must remain active during this period.
A certificate of membership from your medical scheme must be presented monthly for authentication of current membership
Sub-limit of R2 750 per month for a 4 month period
Accidental Death R6 000 principal member
R5 000 adult dependent
R3 000 per child per policy per life
Cancer Cover (Initial Diagnosis)
This benefit will pay you a lump sum upon the initial diagnosis of malignant cancer per beneficiary per annum as defined.
This excludes any incidence of cancer / pre-cancer prior to inception of the policy
Lump sum of R5 500
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
Sub-limit of R2 000