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Sirago – Ultimate Gap Cover

In-Hospital Benefits

Gap Cover
Will settle claims above Medical Scheme rate or at the stated benefit value. In the event of a claim for robotic surgery appearing on the hospital account only, we will cover up to a sub-limit of R30 000 per policy per annum, limited to R12 000 per claim with a maximum of 2 claims per beneficiary per policy per annum.
Up to 500%
Co-payments
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 R16 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 R11 500 per claim
Maximum 3 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 R5 000 per policy per annum
Maximum of R1 250 per claim
Maximum 3 claims per beneficiary
Sub-limit Enhancer
The sub-limit enhancer benefits are limited to MRI scans, intraocular lenses, CT scans and internal prosthesis only. Sub-limit of R100 000 per policy per annum
Maximum R25 000 per claim
Maximum of 2 claims per beneficiary
Limited to 4 claims per policy per annum
Step-down
In the event that your medical scheme provides benefits for rehabilitation as an inpatient in a step-down or sub-acute facility, resulting from an accident, a stroke, or cancer treatment, cover will be provided for ongoing treatments by resident healthcare practitioners during your recovery once medical scheme benefits have be exhausted or limits have been reached
A sub-limit of up to R9 000 per policy applies to this section of cover

Out-of-hospital benefits

Primary Care Consultation Benefits
Applicable to GPs, dentists and alternative therapists. This applies to the Gap portion of the consultation charge only.
Sub-limit of R4 500 per policy per annum
Maximum R400 per claim
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.
Emergency illness benefit: This benefit is applicable to children under the age of 8 who require out of normal consultation hours. All costs related to the 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
A sub-limit of R12 000 is applicable
Day-to-day Specialist Consultation Fee
This applies to the Gap portion of the consultation charge only.
Sub-limit of R6 500 per policy per annum.
Maximum R1 350 per claim.
Maximum 4 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.
Depends on whether your medical scheme option makes provision for these benefits, and will cover the difference between the rate that the service provider charges and the benefit amount on your medical scheme option. If the medical scheme, through medical scheme design, would have made a payment had there been benefit available at the time of claim submission, but the benefits and savings were depleted, Sirago will pay the claim as a stated benefit up to sub-limits / limits per event.
R8 000 sub-limit per policy.
Maximum R1 200 per claim.
Maximum 3 claims per beneficiary per annum
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 R6 600 per policy per annum
Trauma Counselling
You will be covered within the first 6 months after a traumatic incident. Limited to a stated benefit of R750 per claim. 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 R5 000 per policy per annum with a registered medical professional

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
Cancer Benefit – Boost
Applicable to policyholders whose medical scheme option has a defined rand limit for cancer treatment and the rand limit on the medical scheme has been reached. We will cover the costs of the ongoing treatment as per the medical scheme’s registered treatment plan
Subject to OAL
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 300% of the claim. In addition to this, Sirago will make available up to R25 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 preauthorisation and a motivation/letter from your treating provider
Gap portion up to 300%
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 R4 500 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 R4 500 per month for a 6 month period
Accidental Death R15 000 principalmember
R10 000 adult dependent
R5 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 R22 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
Sublimit of R2 000