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Sirago – Plus Gap Cover

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%
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.
Co-payments Charged as a Percentage
If your medical scheme defines your co-payment as a percentage of the benefit, your co-payment benefit will be limited to a maximum payment per claim
Up to R13 000
Penalty Fee Cover
For the voluntary use of a non-designated service provider / network hospital. This includes the use of a partial cover network hospital as determined by your medical scheme.
Sub-limit of R6 500 per claim
Maximum 2 claims per policy per annum
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
Hospital Account Shortfalls
Subject to a sub-limit of R3 000 per policy per annum
Maximum of R800 per claim
Maximum 3 claims per beneficiary
Sub-limit Enhancer
The sub-limit enhancer benefits are limited to MRI scans, CT scans and internal prosthesis only.
Sub-limit of R30 000 per policy per annum
Maximum R10 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 if the medical scheme has paid a portion
A sub-limit of R7 000 is applicable
Day-to-day Specialist Consultation Fee
This applies to the Gap portion of the consultation charge only
Sub-limit of R4 500 per policy per annum.
Maximum R825 per claim.
Maximum 3 claims per beneficiary per annum
Preventative Care Cover
Defined as pap smears, cholesterol tests, blood glucose tests, flu vaccinations, childhood immunisations, bone density scans, prostate specific antigen tests, mammograms, and contraceptive implantation.
R4 000 sub-limit per policy.
Maximum R1 000 per claim.
Maximum 3 claims per beneficiary per annum
Trauma Counselling
You will be covered within the first 6 months after a traumatic event with a registered medical professional. This benefit covers you for, but is not limited to; dread disease, hijacking and/or violent crimes. (At the discretion of the insurer, on the provision of supporting documentation)
A sub-limit of R3 000 per policy per annum
Limited to a stated benefit of R600 per claim

Cancer Benefits

Cancer Co-payment Benefit
This Cancer Co-payment Benefit is applied 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.
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
Limited to R50 000 per beneficiary per annum
Cancer Benefit – Breast Reconstruction
In the event of the medical scheme approving reconstructive surgery on the affected breast, we will cover the Gap portion up to 200% of the claim.
In addition to this, Sirago will make available up to R16 000 for the reconstruction of the non-affected breast.
This benefit is available within the first 12 (twelve) months of the initial mastectomy.
We require, subject to Sirago protocols, which include, but are not limited to: medical scheme pre-authorisation and a motivation / letter from your treating provider
Gap portion up to 200%
Cancer Benefit – PMB
Please note the above benefits are only available in the event that the treatments do not form part of the legislative PMB framework

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 of R3 250 per month for a 6 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 R3 250 per month for a 6 month period
Accidental Death R8 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 R14 000
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