Medical Gap Cover

Extended Cancer Cover

Extended Dentistry Cover
Medical Premium Waiver Policy

Underwritten by Guardrisk Insurance Company,

Guardrisk is a registered and authorised Financial Services Provider

FSP Number 75

Zestlife is an authorised Financial Services Provider

FSP Number 37485

Medical Gap Cover 2016

 Medical
It has become common for medical specialists to charge fees that are well
above the medical scheme rate. When this occurs, a self-payment gap is
created for which you, the medical scheme member become liable.

Gap Even though these self-payment gaps can be extremely costly and frequently
occur, there remains a low level of awareness amongst medical scheme

Cover members as to the extent of this risk exposure. This is due in part to the
mistaken belief that all medical scheme options provide complete cover for
all in-hospital doctor and specialist charges. The reality is that these only
provide funding up to the medical schemes own pre-determined rate,
known as medical scheme tariff (MST). And because doctors and specialists
are free to set their own charges, the MST amount funded is sometimes only a
The most small fraction of the actual charges.

comprehensive
gap cover Medical 800

Self-payment gaps
scheme 700
policy. benefits have
not kept pace
600
with specialist 500
charges Specialists charges
400
meaning that
the magnitude 300
and frequency 200
of self-payment Medical scheme benefits
gaps will 100
continue to 0
grow.
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020

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Medical Medical scheme members, across all schemes, can protect themselves from

Gap
this growing risk by choosing one of three Zestlife Medical Gap Cover
options. Universal, Standard and Core Medical Gap Cover provide a choice
of tiered benefit levels at different monthly premiums.

Cover
Monthly Premium
R281 per Family All three Gap options cover
the main medical scheme
Medical Scheme member and their family
10 & Gap Cover
Medical Premium listed as medical scheme
Waiver
dependants.
Accidental Death
9 & Permanent
Disability This cover is available to members
of all medical schemes and has no:
8 Accidental
Dentistry restrictions on the number of
children covered
Monthly Premium
7 Casualty Ward R262 per Family medical underwriting
requirements
Benefits Covered

6 Internal Prosthesis Internal Prosthesis

Monthly Premium
5 Cancer Cover Cancer Cover
R219 per Family

Non-DSP Hospital Non-DSP Hospital Non-DSP Hospital

4 Co-payment Co-payment Co-payment

3 Co-payment Co-payment Co-payment

2 Out-patient Out-patient Out-patient

1 In-hospital In-hospital In-hospital

Universal Standard Core Medical

Medical Gap Medical Gap Gap Cover
Cover Cover

Cover Options

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Medical
The example below illustrates
the actual amounts paid by the
medical scheme (based on

shortfalls
1.In-hospital Gap Cover MST) and the amount paid by
Cover for up to 500% of Medical Gap Cover.
the medical scheme tariff

covered
Combined Doctor & Specialist
(MST) for in-hospital doctor
and specialist charges, e.g.
Gap Cover

Charges - R33 500

GPs, specialists, surgeons, Payment
anaesthetists, radiologists, R22 200
pathologists. This cover is
provided without an
annual maximum claim
limit. Medical Scheme
Payment R11 300

The following illustration shows just some of the many in-hospital

shortfalls that have been paid.
Combined Doctor & Specialist Charges

Gap Cover Payment

Medical Scheme Payment

R91 800
R86 100
R145 000

R71 100
R128 200
R112 300

R53 200
R42 200 R42 100
R25 900

R16 400
R18 150

R19 900

R10 800 R13 600

R7 350 R6 300 R9 500

Natural Child Birth Hernia Repair C-Section Cardiac Bypass Spinal Surgery Breast Cancer
Child Birth Surgery Surgery

Medical Procedure

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 2. Out-patient Cover
Doctor and specialist shortfalls are covered on the procedures listed below irrespective of
whether they are performed in-hospital or at an out-patient facility. Cover is up to 500% of the
MST and provided without annual maximum claim limit.

MRI Magnetic Resonance Imaging Bronchoscopy Hernia Repairs, limited to:

PET Positron Emission Tomograph Coronary angioplasty - Inguinal Hernia
CT Scan Computer Axial Coronary angiogram - Femoral Hernia
Tomography Oesophagoscopy - Umbilical Hernia
Chemotherapy or radiotherapy Gastroscopy - Epigastric Hernia
Kidney dialysis Entroscopy - Spigelian Hernia
Tonsillectomy Colonoscopy
Grommets Vasectomy Myringotomy
Childbirth in a non-hospital setting Prostate biopsy Arthroscopy
Surgical Biopsy of Breast Lump Cataract removal Carpal Tunnel Release
Sinus surgery, limited to: Orchidopexy Ganglion surgery
- Frontal sinus Pterygium removal Bunionectomy
- Functional endoscopic sinus surgery Trabeculectomy Needle biopsy of the liver
- Bilateral function endoscopic sinus Direct laryngscopy Tubal ligation
surgery Hysteroscopy Cervical laser ablation
Incision, drainage of Bartholins cyst Dilatation and curettage
Marsupilisation of Bartholins cyst

3. Co-payment Cover
Upfront co-payments required by medical schemes from their members for hospital
admissions, scans and certain surgical procedures are covered. This cover is provided
without an annual maximum claim limit.
Co-payment Amount

R7 500

R 5000

R3 650

R1 600
R950

Gastroscopy Hospital Admission Colonoscopy Hernia Repair Spinal surgery

Examples of Co-payments Covered

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 4. Non-DSP hospital co-payment cover
Co-payments that are charged by medical schemes, expressed in a Rand
amount as opposed to a percentage when members use a non-DSP hospital
are covered up to R8 000 per year, per policy, and subject to one claim per
policy per year.

5. Cancer cover
In addition to the shortfalls for cancer treatment and procedures in points 1, 2, 3
and 4; three additional policy benefits are provided:
Lump sum cancer cover - R25 000 is paid out on first time diagnosis of
cancer. This benefit payment is not dependant on actual treatment costs.
Co-payment cover Cover for the co-payment specified by the
medical scheme for cancer treatment after the exhaustion of a specified
limit or threshold. This cover is subject to a maximum co-payment of 20% in
any one claim and will pay up to R250 000 per individual per year.
Cosmetic breast reconstruction cover Up to R20 000 cover for surgical costs that
are not covered by medical scheme for breast reconstruction of the non-

Medical
affected breast in the event of a single mastectomy resulting from cancer.

6. Internal prosthesis cover

Gap Cover Cover of up to R30 000 per policy per year is provided for cover shortfalls on
the cost of internal prosthesis.

7. Casualty cover
The most Accident related charges incurred for in-hospital casualty ward treatment are
covered. This benefit covers the facility fee, consultations, medications, radiology
and pathology associated with admission to a registered hospitals casualty
comprehensive facility due to an accident. Where a full in-hospital admission follows casualty
ward treatment, only the shortfall amount not covered by the medical
gap cover policy. scheme will be covered. This benefit will pay up to R5 000 per policy per year.

8. Dental cover
R14 000 Accidental tooth fracture cover is provided per person per year.
This cover is payable at a flat rate of R2 000 per tooth irrespective of cover
provided by the medical scheme.

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 Medical 9. Accidental death and permanent disability cover
A R25 000 lump sum benefit is paid in the event of accidental death or

Gap
permanent disability.

Emergency transportation / search and rescue maximum of R25 000

Cover If as a result of an accident you are in danger of being injured or you have
been injured, we will pay the related costs and expenses up to R25 000
(for each and every claim) for your necessary emergency
transportation or for your search and rescue, including freeing and
bringing you to a place of safety.
We will not pay these costs in the case where injuries are not as a
The most result of an accident or if the accident is unlikely to result in an injury
to you.
comprehensive Life support equipment maximum of R25 000
If as a result of an accident, life support machinery, equipment or
gap cover apparatus is needed, we will pay for the costs and expenses to hire
these items up to R25 000 (for each and every claim).
policy.
Trauma counselling up to R750 per visit, with an annual limit of R25 000
If you are subjected to, or a witness of, an act of violence or a
traumatic accident, we will refund you for counselling fees paid by
you as a result of the violence or traumatic accident.
An act of violence includes events such as murder, assault,
robbery, rape, kidnapping or hijacking which is reported to the
police and for which you have a case number.
The maximum that we will pay under this benefit is R750 per
counselling session, up to R25 000 per policy per year.

Accidental death, permanent disability, emergency transportation, life

support equiptment and trauma counselling cover, as outlined above,
applies to all individuals under the policy up to age 65.

10. Medical Premium Waiver

This benefit covers the actual medical scheme and gap cover premium
amount in the event of the policyholders death or permanent disability.
This cover is subject to the policyholder having not reached the age of
65 and a maximum payment of R5 600 per month, for three
consecutive months.

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 Optional claim excess
Policyholders can reduce their monthly premium by choosing to apply a R1 500 claims excess to their
policy. When applied, in-hospital and out-patient shortfall benefits, co-payment benefits and the sub
limit benefit will only be covered for the amount exceeding R1 500.

Monthly premiums with claims excess applied

Monthly premium without claim Monthly premium with
Medical Gap Cover option
excess claim excess
Universal R281 R248
Standard R262 R230
Core R219 R195

Important Waiting periods

No general waiting period applies. This means that valid claims for

policy
procedures that are not defined as pre-existing or are related to childbirth
or listed as condition specific will be covered from the outset.

terms and Pre-existing conditions

In the first 12 months no cover will be provided for treatment of conditions

conditions
that existed in the 12 months prior to the policy commencement date.
Previously diagnosed cancer will be regarded as a pre-existing condition
unless it has been in remission for at least 5 years. This pre-existing condition
exclusion applies to all medical conditions including those where waiting
periods are applied.
These apply to
all three Childbirth
Zestlife No cover will be provided for childbirth claims for the first 10 months of cover.

Medical Gap
Cover policy
types.

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Important policy terms and conditions (Continued)

Condition specific procedures

For the procedures listed below no cover will be provided for the first 6 months of cover and from months 7-12,
only 50% of the normal cover will be provided. After month 12, full cover is provided.
Joint replacements Arthroscopic procedures
Spinal surgery including spinal fusion Nasal surgery including sinus surgery
Tonsil and Adenoid surgery Cataract surgery
Hysterectomy Grommet insertion
Hernia repairs Dentistry
Cardiac surgery

These waiting periods may be waived in circumstances where treatment is required due to accident or
injury after the commencement of cover. Or, in the case where hysterectomy, tonsillectomy or
adenoidectomy is required following the diagnosis of cancer, after the commencement of cover. Or,
in the case of cardiac treatment arising from an event or incident occurring and/or being diagnosed
after policy commencement.

General exclusions
No benefits are payable if a claim arises directly or indirectly from:
Nuclear weapons or nuclear or ionizing radiation.
Suicide, attempted suicide or intentional self-injury.
The taking of any drug or narcotic unless prescribed by and taken in accordance with the instructions of a
registered medical practitioner (other than the insured person) or any illness caused by the use of alcohol.
Illegal behaviour or as a result of breaking the law of the Republic of South Africa.
Participation in war, terrorist activity, invasion, rebellion, active military duty, police duty, police reservist duty,
civil commotion, labour disturbances, riot, strike or the activities of locked out workers.
Aviation, except on a commercial flight as a fare-paying passenger.
Any form of race or speed test (other than on foot or involving any non-mechanically propelled vehicle
vessel, craft or aircraft).

Specific exclusions
No benefits are payable for:
Cosmetic surgery Treatment for obesity
Cancer treatment outside of the borders of South Africa Claims not covered by medical scheme
Private and home nursing Hospital charges
Medication and other materials Prosthesis other than artificial joints

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Optional EXTENDED CANCER COVER
This is an optional lump sum policy benefit of either R75 000 or R175 000,

extra payable in the event of first-time diagnosis of cancer. This cover is

available up to age 65 and can be added to either of the three policy
options.

cover R200 000

R175 000
Cancer and
dentistry are the
two areas where
medical scheme Extended
Cover
R100 000 R175 000
members
Extended
face the most R75 000
Cover
R175 000
Extended
substantial risk of Cover
R75 000
treatment funding
Extended
Cover
shortfalls. In R75 000
R25 000
response to this Embedded Embedded Embedded
Cover Cover Cover
need, Extended R0
R25 000 R25 000 R25 000

Dentistry and Core Universal & Core + Universal & Core + Universal &
Standard Extended Cover Standard Extended Cover Standard
R75 000 + Extended Cover R175 000 + Extended Cover
Extended Cancer R75 000 R175 000

Cover are Lump Sum Pay-out on First Time Cancer Diagnosis

valuable top-up
To qualify for this Extended Cancer Cover, policyholders are required
benefits that are
to answer an underwriting question relating to previous diagnosis or
available on all treatment of cancer. This cover has a termination age of 65 and a
6-month waiting period from the date of application.
three Medical
Gap Cover Extended Cover Monthly Premium
options. Cancer Cover R 75 000 R48
Cancer Cover R175 000 R90

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Optional EXTENDED DENTISTRY COVER
Extended Dentistry Cover offers optional lump sum cover for emergency,

extra accidental and specialised dentistry and can be added to all three
Zestlife Medical Gap Cover options.

cover This cover insures the policyholder and their medical scheme dependants
for all the conditions listed in the first column of the table below. The middle
column lists the treatment that may be required and the third column lists the
fixed pay out for the insured conditions.
(Continued)
INSURED CONDITION LIKELY TREATMENT COVER AMOUNT
Impacted wisdom tooth (teeth in Surgical Tooth Removal R1 000 per tooth
the process of eruption that are not
impacted are excluded)
Periodontitis (severe infection of the gums Gum Surgery R1 500 per event
where the attachment of the tooth to the
gum is broken down)
Jaw Fracture Surgery R15 000 per event
Dental Emergency (dental pain or Emergency Root Canal, R1 000 per event
infection that requires immediate temporary crown,
treatment for relief) temporary filling
Accidental Tooth Fracture (50% of the Crown, splinting, bridge R4 000 per tooth
visible tooth is lost due to accident
resulting in permanent nerve damage)
Severely decayed or damaged tooth Crown R3 000 per tooth
(Two thirds of the tooth is lost due to A maximum of 2 teeth
decay or trauma) are covered in 12 months
Impaired chewing due to loss of tooth / Removable Denture R5 000 per jaw
teeth (Teeth can be lost due to infection Paid once per upper or
or trauma, 2nd and 3rd molar positions lower jaw per 24 months
are excluded)
Reduced dental stability due to tooth loss Implant or Bridge R10 000 per tooth
(Tooth is lost resulting in adjacent teeth Limited to one claim in
potentially changing position causing the 12 months
bite to become unstable)

Following a 6-month upfront waiting period, cover is provided to the

policyholder and their medical scheme dependants, subject to a 12-month
pre-existing condition exclusion, up to the age of 65.

Extended Cover Monthly Premium

Dentistry R238

CONTACT US
For further information and expert advice please contact
Zestlife on (021) 180 4220 or gap@zestlife.co.za.

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