A problem medical aid members face is that surgeons, anaesthetists and other specialists often charge substantially more than medical aid rates. When this occurs, you as the medical aid member becomes liable to pay for the shortfall.
The solution is for medical aid members to insure themselves against medical expense shortfalls through either of Zestlife’s top-of-the-range Gap Cover options.
Please note that Gap Cover is not a medical aid or a substitute for medical aid cover. Gap Cover is top-up health insurance that provides cover for medical expense shortfalls that arise when medical aids only cover treatment and/or procedure costs in part. To assist you in choosing the Gap Cover option that best suits your needs please study the benefits summary below.
OPTIONAL EXTRA COVER
In addition to the cover described you also have the option to boost your cancer and dentistry cover. These extended cover options address the two most substantial funding shortfall risks that all medical aid members face. We therefore encourage you to study the extended cancer and dentistry cover benefits and consider protecting your dependents and yourself from these risks. Please refer to our brochure for full details.
How much does it cost?
Frequently Asked Questions
The policy is underwritten by Guardrisk Insurance Company Ltd.
Only for claims incurred while you are hospitalised and for certain procedures performed on an out-patient basis at a doctor’s surgery like a gastroscopy, colonoscopy, removal of cataracts and certain biopsies, MRI scans, CT scans and PET scans.
No, day-to-day services such as doctor’s visits, specialists visits, spectacles etc are not covered.
Surgical or medical procedures performed on an out-patient basis are limited to thesurgical or medical procedures listed in the policy document. Below are some examples (See the brochure for a full list of procedures covered):
- Surgical Biopsy of Breast Lump
- Prostate biopsy
- Cataract removal
- Carpal Tunnel Release
- Ganglion surgery
- Childbirth in a non-hospital setting
- MRI – Magnetic Resonance Imaging
- PET – Positron Emission Tomography
- CT Scan – Computer Axial Tomography
No, this policy can be used on any South African registered medical aid.
The list of exclusions include the standard insurance exclusions, such as sickness or injury, that are caused from nuclear weapons or material, injury from an accident while over the legal alcohol limit, active participation in war, police duty, civil commotion. There are also a number of specific exclusions such as cosmetic surgery and treatment for obesity and any event not covered by your medical aid. It is however worth studying the full list of exclusions which appears in the policy document.
There is no 3-month general waiting period.
No general or condition specific waiting periods apply. However no benefits can be claimed for a period of 12 months from the start date of cover in respect of medical conditions, for which in the 12 months before the start date of the cover, medical advice, diagnosis, care or treatment was received or would reasonably have been recommended.
Pregnancy before the start date of cover will be regarded as a pre-existing condition and any pregnancy or birth related claims will be excluded for 12 months from the start date of the cover.
If prior to the start date of Zestlife Gap Cover a policyholder had cover under another Medical Expense Shortfall Policy, then the pre-existing condition waiting period will only be applied to the unexpired part of the pre-existing condition waiting period from the previous policy. The pre-existing condition waiting period will however apply for the full period of 12 months for any benefit not provided under previous Medical Expense Shortfall Policy.
There are no medicals required when applying for this policy and cover is immediately available.
Yes. The premium amount will be reviewed on 1 January each year and you will be notified of any premium increase on 1 (one) months notice.
There is absolutely no additional policy fee; the costs incurred for administration are covered in your premium.
The first premium will be debited on a day of your choice.
Your policy documents will be sent to you within 1 week of taking out this cover.
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. Please be aware however that cover for certain benefits cease at age 65.
There is no maximum entry age..
Within 6 months of a hospital admission giving rise to a claim you need to submit a claim. This can be done by contacting the Zestlife administrator who will advise you of the documents that will have to be completed in submitting a claim.
Benefits will either be paid to you (in which case you are responsible for settling the accounts with the medical practitioner or service provider) or directly to the medical practitioner or service provider, at the discretion of the insurer.