Gap Cover Frequently Asked Questions

Old Mutual Gap Cover pays in-hospital & out-of-hospital medical bills that are not full covered by your medical aid. Gap Cover is not medical aid but rather the best medical insurance option available to cover your existing medical aid shortfall in South Africa.

Find out more about what medical gap cover is, what Old Mutual Gap Cover pays for and what is not covered, how Gap Cover works, and then simply apply for Gap Cover online to make sure you and your family are not left with huge medical bills not fully covered by your medical aid.

Anyone who is a member of a registered South African medical aid and meets the requirements of an Eligible Member (please speak to a consultant for the full definition of an Eligible Member) can apply. Members on different medical aids can be covered on the same Old Mutual Gap Cover policy.

The following are seen as covered events: hospitalisation for accidental harm, illness or other health incidents; oncology treatment, including chemotherapy, radiotherapy or other drug regimen. Should you experience a physical trauma event, there is an allowance for treatment in a casualty ward.

The total cover amount is R150 000 per beneficiary, per year. This annual limit includes in-hospital costs, as well as some out-of-hospital costs.

Cover is provided for procedural co-payments (the excesses imposed in terms of your medical aid rules) for procedures performed as an in-patient or an out-patient, including MRI, CT, PET, SPECT and Ultrasound Scans (A full list of the defined procedures is available from a consultant.) Benefits also include additional cover for a co-payment charged when using a non-designated hospital, limited to R12 000 per family, per annum.

Gap Cover doesn't cover procedures that aren't covered by your medical aid.

Gap Cover doesn't include benefits for PMB claims. Prescribed Minimum Benefits (PMBs) are a set of defined benefits to ensure all medical aid members have access to certain minimum health services, regardless of the benefit option they have selected.

Normal visits to your general practitioner or specialist, and auxiliary services on a day-to-day basis are not part of your policy benefit.

No. Cover is available immediately, subject to relevant waiting periods. However, underwriting may be applied at claim stage.

A spouse/ life partner and all children registered as dependants (including full-time students and permanently disabled children) on your medical scheme will be covered on your Old Mutual Gap Cover policy. Children must be registered on your/your spouse's medical scheme as a child dependant. No other extended family will be covered.

Yes. There is a 3-month general waiting period and a 12-month waiting period for pre-existing conditions.

Claims must be submitted as soon as your medical aid has paid their portion of the account, but no later than 4 (four) months after the end of the Covered Event. No claim can be processed if any documentation is outstanding. 

A completed claim form, available on request (email omclaims@insuremed.co.za, phone 0861 484 485) or download, must be accompanied by: detailed copies of all relevant doctors’ accounts, a clear copy of the Hospital account, detailed medical aid claims statement reflecting the shortfall to the doctor, a copy of your medical aid authorisation confirmation, and a copy of the medical aid membership certificate.

Claims take 5 - 10 working days to be processed and may be sent to omclaims@insuremed.co.za or faxed to 0865 784 921.

R186.62 per family, per month. If a family member over the age of 60 is included on the policy, the policy premium will be R242.11 per month.

The Council for Medical Schemes recommends a rate medical practitioners should charge for medical procedures. This recommended rate is the medical aid rate, used by medical aids to determine what to reasonably pay medical practitioners for medical procedures performed on the medical aid’s members.

No. Gap Cover isn't a medical aid and the cover is not the same as that of a medical aid. This policy is not a substitute for medical aid membership.

 

If you have any questions, or would like to find out more,
speak to one of our consultants 0860 665 463.

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