Momentum GapCover+
Underwritten by Guardrisk Insurance Company Limited, an authorised Financial Service Provider and Licensed Non-life insurer. FSP No. 75
Why worry about potential shortfalls for in-hospital procedures and other healthcare related expenses not covered by your medical scheme option when you can get Momentum GapCover? Momentum GapCover offers you supplementary cover to assist with shortfalls in the event of hospitalisation involving surgery or medical treatment, as well as for certain procedures performed out-of-hospital or in a day clinic, provided you have obtained authorisation. You can choose between the more affordable GapCover Primary, or the more extensive benefits offered by GapCover Supreme.
Momentum GapCover Supreme | |
|---|---|
Shortfall benefits(these benefits aggregate to a maximum of R200 000 per insured person per year) | |
| Benefit for shortfalls in medical practitioner cost | Covers the shortfall between what the medical practitioner charged and the medical scheme paid, up to three times the amount paid by the medical scheme. Momentum GapCover Supreme also covers you for certain medical procedures performed out of hospital, in day clinics or other registered facilities. These shortfalls are also covered up to three times the amount paid by the medical scheme. In total, you would therefore be covered up to the following rates, depending on your option:
|
| Allied professionals | We cover the shortfall between what the allied professional has charged and what Momentum Medical Scheme has paid for in-hospital care following an associated in-hospital procedure. This is paid up to three times the amount paid by Momentum Medical Scheme towards in-hospital shortfalls and is limited to R2 500 per policy per year. You can view the list of allied professionals that we cover below. |
| Co-payments | Covers co-payments applied by the medical scheme for hospital admissions, procedures and certain day clinic procedures/treatment. This benefit does not cover co-payments payable for voluntary use of non-Designated Service Providers. |
| Co-payments on oncology treatment | Covers the 20% co-payment applied to oncology treatment after the medical scheme limit has been reached. |
| Robotic procedure shortfall benefit | Should your condition require the use of robotic assisted surgery, we will cover the shortfall on the medical practitioners performing the surgery up to three times the amount paid by your medical scheme. |
| Robotic procedure co-payment benefit | Should your condition require the use of robotic assisted surgery and your medical scheme levies a co-payment, we will cover you up to R12 000 per policy per year. |
| Casualty benefit | If you visit a casualty ward within 24 hours of an emergency caused by an accident, we will pay up to R24 000 of all costs incurred. This benefit is limited to five casualty visits per family per year. Three of these visits, limited to R5 000 per policy per year, may be used in an emergency (regardless of whether it was an accident) for a child aged eight years or younger. The cost of these three visits would count toward the R24 000 annual limit. |
| Internal prosthesis shortfall benefit | Covers shortfalls on internal prosthesis costs, up to a maximum amount of R35 000 per policy per year. Stents and pacemakers are covered up to a sub-limit of R8 000 per claim event. This sub-limit is subject to the overall policy limit of R35 000 |
Assist benefits(these benefits do not aggregate to the R200 000 cap) | |
| Cancer assist benefit | If you are diagnosed for the first time with minimum stage 2, local and malignant cancer, we will pay you R8 000. If, however, you are diagnosed with minimum stage 2, regional and malignant cancer, we will pay you R20 000. If, after receiving the R20 000 benefit, your medical scheme pays more than R200 000 for the cost of your oncology treatment within 12 months of your diagnosis, we will pay you a further R15 000. This benefit is payable once in a lifetime per person covered on the policy. |
| Breast reconstruction benefit for non-affected breast | Should you be diagnosed with breast cancer and require cosmetic breast reconstruction for the non-affected breast due to a mastectomy, we will provide assistance cover of R15 000 per policy per year. This can be used to recover the costs incurred for the treatment or related to the treatment. |
| Accident assist benefit | Benefit of R55 000 payable for death or permanent disability due to an accident. Subject to one claim per insured per lifetime. |
| Violent crime benefit | If you or a dependant successfully claims the Accident Assist benefit and the claim event was due to a violent crime, we will double the amount that we pay to R110 000. |
| Premium waiver benefit | If you or a dependant who pays the monthly premium due on this policy dies or becomes permanently and totally disabled as a result of an accident while covered under this policy, we will assist your dependants in covering the cost of their monthly medical scheme contributions and gap cover premium by paying an amount of R36 000 upfront. |
| Trauma and bereavement counselling benefit | If you are a victim of, or witness to, an act of violence (such as murder, assault, robbery, rape, kidnapping or hijacking), a traumatic accident, or you suffer the loss of an immediate family member we will pay you a fixed amount of R800 per session for any trauma counselling fees, limited to R30 000 per policy per year. |
| Baby bump benefit | If you fall pregnant while covered on the policy, we will pay you an upfront amount of R2 500 to assist you with any unexpected costs. |
Please note that you may only apply for Momentum GapCover if you are a member of Momentum Medical Scheme.
Momentum GapCover Supreme premiums
| Momentum GapCover Supreme <42 – Family | R426 |
| Momentum GapCover Supreme <42 – Single | R390 |
| Momentum GapCover Supreme >42 – Family | R603 |
| Momentum GapCover Supreme >42 – Single | R545 |
| Momentum GapCover <30 - Single | R259 |
| Momentum GapCover >65 - Single | R734 |
Please note that you may only apply for Momentum GapCover if you are a member of Momentum Medical Scheme. Rates are per policy per month. The age group indicated applies to the principal member. No dependants may be added to Momentum GapCover if the principal insured is over 65, or on <30 GapCover.
Momentum GapCover Primary | |
|---|---|
Shortfall benefits(these benefits aggregate to a maximum of R200 000 per insured person per year) | |
| Benefit for shortfalls in medical practitioner cost | Covers the shortfall between what the medical practitioner charged and the medical scheme paid, up to three times the amount paid by the medical scheme. Momentum GapCover Supreme also covers you for certain medical procedures performed out of hospital, in day clinics or other registered facilities. These shortfalls are also covered up to three times the amount paid by the medical scheme. In total, you would therefore be covered up to the following rates, depending on your option:
|
| Co-payments | Covers co-payments applied by the medical scheme for hospital admissions, procedures and certain day clinic procedures/treatment. This benefit does not cover co-payments payable for voluntary use of non-Designated Service Providers. |
| Casualty benefit | If you visit a casualty ward within 24 hours of an emergency caused by an accident, we will pay up to R12 000 of all costs incurred. This benefit is limited to five casualty visits per family per year. Three of these visits, limited to R2 500 per policy per year, may be used in an emergency (regardless of whether it was an accident) for a child aged eight years or younger. The cost of these three visits would count toward the R12 000 annual limit. |
Momentum GapCover Primary premiums
| Momentum GapCover Supreme <42 – Family | R384 |
| Momentum GapCover Supreme <42 – Single | R358 |
| Momentum GapCover Supreme >42 – Family | R549 |
| Momentum GapCover Supreme >42 – Single | R498 |
Please note that you may only apply for Momentum GapCover if you are a member of Momentum Medical Scheme. Rates are per policy per month. The age group indicated applies to the principal insured. Momentum GapCover Primary is not available to principal members under 30 or over 65.
Quotes for employer groups
Premiums for groups of more than 20 members that are not covered on another gap provider will be calculated based on the demographics of the group. We take into account the average age of the group, the number of members and whether membership is voluntary or compulsory. If the group is more than 20 members and covered on another gap provider, we will require a minimum of three years loss ratio or average claim spend per member per month.
Waiting Periods
Individuals or groups under 20 members
- 3-month general waiting period – applies to all claims
- 9-month waiting period – applies to any pre-existing physical defect, injury, disease, illness or medical condition for which medical advice, diagnosis, care or treatment was recommended or received within the past 12 months
- 12-month waiting period applies to:
- Cancer: where an insured has received or was recommended for medical advice, diagnosis, care or treatment for cancer of any type in the past 12 months
- Birth or pregnancy: where an insured has given birth within the past 12 months or is currently pregnant
Voluntary groups over 20 members
- 3-month general waiting period: Does not apply
- 9-month waiting period: Applies to pre-existing conditions
- 12-month waiting period: Applies to cancer of any type, pregnancy and birth
Compulsory groups over 20 members – all waiting periods will be waived
- 3-month general waiting period: Not applicable
- 9-month waiting period for pre-existing conditions: Not applicable
- 12-month waiting period: Not applicable
How to claim
Momentum GapCover shortfall claims are processed seamlessly. This means that our system will automatically pick up any potential GapCover claims without you having to complete a claim form or submit documentation. We will notify you of the potential gap cover claim and shortly thereafter we will let you know the outcome of the claim. Our seamless claims process works with the following claims:
- Shortfall for medical practitioners for in-hospital procedures (Supreme and Primary)
- Co-payments (Supreme and Primary)
- Oncology co-payments (Supreme only)
- Internal prosthesis (Supreme only)
- Casualty benefit (Supreme and Primary)
- Baby bump benefit (Supreme only)
If you are claiming for one of the following Assist benefits, you will need to submit a claim form to provide us with additional information:
- Cancer assist pay-out for cancer diagnosis
- Accidental death/disability
- Violent crime
- Premium waiver
- Trauma and bereavement counselling
We cover these out-of-hospital or day clinic procedures
Below is a list of all the out-of-hospital/day clinic procedures we will cover:
- Urology - Circumcision (due to medical necessity), cystoscopy, orchidopexy, prostate biopsy, vasectomy
- Ear, nose, throat - Adenoidectomy, direct laryngoscopy, grommets, myringotomy, sinus surgery and tonsillectomy
- Orthopaedic - Arthroscopy, bunionectomy, carpal tunnel release, ganglion surgery
- Radiology - CAT, MRI and PET scans, nuclear radiology, varicose vein removal, x-rays
- Gastro-intestinal - Closure of colostomy, colonoscopy, endoscopy, gastroscopy, laparoscopy, oesophagoscopy, haemorrhoidectomy
- Gynaecology - Cervical laser ablation, dilatation and curettage, hysteroscopy, tubal ligation
- Cardiovascular - Coronary angioplasty and angiogram
- Obstetrics - Childbirth in a non-hospital setting
- Renal - Kidney dialysis
Allied professionals that we cover
- Chiropractors
- Clinical technologist
- Genetic counsellors
- Myotherapists
- Occupational therapists
- Orthoptists
- Osteopaths
- Perfusionist
- Physiotherapists
- Podiatrists
- Speech pathologists
What we do not cover
Medical expense shortfall benefit
- Shortfalls where your medical scheme has not paid the first portion of costs
- Hospital and day clinic fees including theatre charges, ward charges or any other hospital or day clinic costs
- Pre-admission or out-of-hospital consultation costs
- Materials or medication used during a procedure
- Dental implants
- Appliances (wheelchairs, crutches, braces, etc)
- Out-of-hospital dental procedures
- Home and private nursing
- Procedures for cosmetic purposes
- Exploratory procedures such as blood tests, pap smears, ultrasounds, etc
- Procedures that are paid for by your medical scheme on an exception or ex-gratia basis
- Procedures performed specifically for the treatment of obesity
- Any costs levied as a direct result of the patient's Body Mass Index (BMI) or bodily weight
- Hospice or step-down facilities
- Medical examinations performed annually or routinely such as pap smears, annual check-ups, etc
- Anxiety disorders, mood disorders, psychotic disorders, dementias and eating disorders
- Transportation costs (including resuscitation) in an emergency vehicle or aircraft and emergency medical service costs
- Auxiliary or para medical services (speech therapists, audiologists, physiotherapists, etc)
Co-payment benefit
- Co-payments applied for the use of a non-Designated Service Provider (non-DSP)
- Co-payments applied for not adhering to the medical scheme's protocols (eg not being referred to a specialist by a GP, not obtaining a pre-authorisation for a procedure, etc)
- Co-payments applied for use of a private ward or any other special request not covered by your medical scheme
- Co-payments applied to a condition for which you are in a waiting period
Oncology co-payment benefit
- Co-payments applied for undergoing treatment with a non-Designated Service Provider
Internal prosthesis shortfall benefit
- Shortfalls where your medical scheme has not paid the first portion of costs
- External prostheses or dental implants
Casualty benefit
- Elective procedures undertaken at a casualty ward
- Casualty ward visits due to illness for children older than eight years
Robotic procedure shortfall benefit
- Any other shortfalls related to the procedure with exception of the medical practitioner costs
Robotic procedure co-payment benefit
- Any amount exceeding the R12 000 annual amount
Benefit for first time cancer diagnosis
- Any diagnosis which does not meet the minimum criteria for eligibility of the benefit
- Any diagnosis which is not a first-time diagnosis
- All skin cancers
Benefit for accidental death or accidental permanent and total disablement
- Death or permanent and total disablement not directly due to an accident as defined in the policy
- Disability which is not total and permanent as defined in the policy
Benefit for accidental death or accidental permanent and total disablement due to a violent crime
- Death or permanent and total disablement which is not directly due to a violent crime as defined in the policy
- Disability which is not total and permanent as defined in the policy
Benefit for trauma or bereavement counselling
- Any counselling that is not related to an act of violence or a traumatic accident
- Any counselling not undertaken by a counsellor as defined in the policy
- Counselling for the death of a family member not defined in our policy wording
Baby Bump benefit
- Any pregnancy that is not confirmed by the specific criteria set out in the policy
General exclusions
We do not cover any claims that arise from the below events:
- Participation in war, invasion, terrorist activity, rebellion, active military duty, police duty, police reservist duty, civil commotion, labour disturbances, riot, strike or the activities of locked out workers
- Nuclear weapons, nuclear material, ionising radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the burning of nuclear fuel, including any self-sustaining process of nuclear fission (the splitting of an atomic nucleus into small parts)
- Taking of any legal drug unless it has been prescribed by a registered medical practitioner (other than you) and you are following the instructions of the medical practitioner in your taking of the drug
- Taking of any illegal drug
- Illegal behaviour or as a result of breaking any law of the Republic of South Africa
- Suicide, attempted suicide, intentional self-injury or any form of exposure to danger
- Aviation except if you are on a commercial flight as a fare-paying passenger
- Participation in sports on a professional basis. Professional means that you are paid to participate in the sport
- Participation in hazardous (dangerous) sports, including hang-gliding, kite-surfing, mountaineering, paragliding, scuba diving and skiing
- Participation in any form of race or speed test, other than on foot or involving any non-mechanically propelled vehicle, vessel, craft or aircraft.
Terms and conditions of cover
All of the benefits offered are subject to the terms and conditions of the policy. A comprehensive description of the terms and conditions, as well as the exclusions, is available upon request or in the policy document.
This information is protected by applicable intellectual property laws and cannot be copied, distributed or modified for commercial purposes. Whilst every effort has been made to ensure that the information contained herein is current, fair and accurate, this cannot be guaranteed. The use of this information by any third party shall be entirely at the third party's discretion and is of a factual nature only. The information contained herein – including client endorsements – does not constitute financial advice as contemplated in terms of the Financial Advisory and Intermediary Services Act 2002. Guardrisk Insurance Company Limited does not expressly or by implication represent, recommend or propose that products or services referred to herein are appropriate to the particular need of any third party. Guardrisk Insurance Company Limited does not accept liability due to any loss, damage, costs and expenses which may be sustained or incurred directly or indirectly as a result of any error or omission contained in the above document.
Momentum GapCover is not a medical scheme and cover is not the same as that of a medical scheme. This product is not a substitute for medical scheme membership.
Disclaimer: +Momentum Medical Scheme members may choose to make use of additional products available from Momentum Group Limited and its subsidiaries as well as Momentum Multiply (herein collectively referred to as Momentum). Momentum is not a medical scheme and is a separate entity to Momentum Medical Scheme. Momentum products are not medical scheme benefits. You may be a member of Momentum Medical Scheme without taking any of the products offered by Momentum.