TOP-UP COVER / GAP COVER
In simple terms, what is top-up cover / gap cover?
Top-up / GAP Cover is a Short-Term Health Insurance Policy which provides for the shortfall in cover where Doctors and Specialists charge ‘above the medical aid rates’ of cover. GAP Cover works in conjunction with your medical aid.
GAP / Top-up Cover works by covering the difference or shortfall between what your Doctor charges and what your Medical Aid pays from the Risk or Hospital benefit.
You may also want to know why you need GAP Cover? Depending on the option you select, you will also have cover for Medical Aid Co-payments, Sub-Limits, and Cancer Treatment Shortfalls.
Gap Cover is underwritten by GENRIC Insurance Company Limited (FSP: 43638).
GENRIC is an authorised Financial Services Provider and licensed non-life insurer
Please Note: GAP Cover is not a Medical Scheme, and the cover is not the same as that of a Medical Scheme. GAP Cover is not a substitute for a Medical Scheme Membership.
TOP-UP COVER / GAP COVER PRODUCTS
We offer 7 affordable financial Top-up/GAP Cover options for essential health-related expenses, designed to provide the right cover for medical expense shortfalls at all stages of the family lifecycle.
Explore our Top-Up Cover / GAP Cover Products below.
GAP Student Cover
Our GAP Student Cover is for Individuals between the ages of 18 and 27 and offers Financial Cover for health-related expenses at an affordable price for those who have become too old to stay on their parent’s policy, but do not necessarily fit the Medical Scheme’s definition of a Student. The insured will receive a benefit that mainly covers in-hospital costs with additional extensive cover for those unplanned medical emergencies.
Affordable Financial Cover for Health-related Expenses
Individuals (18 to 27 Years)
Too old to stay on Patent’s Policy
Not Permanently Employed &/or Still Studying
HOW TO SUBMIT A GAP COVER CLAIM
We care that the claims process is seamless. If you need any assistance submitting your claim or any advice, please call our friendly customer service consultants on 010 021 0260.
Please always consult your broker if in doubt.
All required relevant documents must be submitted to us within 180 (hundred and eighty) days after the event date. Claims can be emailed to claims@curaadmin.co.za.
Claim Documents Required:
- Cura Administrators claim form completed and signed by the policyholder.
- Detailed hospital and related accounts substantiating your claim.
- Medical scheme statement reflecting all the payments made by your medical scheme for the treatment dates of the health event.
- Completed medical reports substantiating the clinical information or any other documentation if requested by our claims team.
- Pre-authorisation letter from your medical scheme for co-payment claims.
- Proof of banking details.
- Value Added Benefit claims: Documentation and certification which may include reports from a registered medical practitioner confirming total permanent disability.
- For an initial Cancer Diagnosis, we require a histology report.
For Claims Relating To Accidental Death:
- Cura Administrators claim form completed and signed by the policyholder.
- Detailed hospital and related accounts substantiating your claim.
- Medical scheme statement reflecting all the payments made by your medical scheme for the treatment dates of the health event.
- Completed medical reports substantiating the clinical information or any other documentation if requested by our claims team.
- Pre-authorisation letter from your medical scheme for co-payment claims.
- Proof of banking details.
- Value Added Benefit claims: Documentation and certification which may include reports from a registered medical practitioner confirming total permanent disability.
- For an initial Cancer Diagnosis, we require a histology report.
Important Information
- Any benefit payable in respect of hospital confinement shall only become due at the end of a period of such confinement;
- Any claims in terms of this policy will lapse after 12 calendar months from the date of occurrence of the insured incident if the claim is outstanding and not a subject of a then pending court case; and
- We must assess a claim within a reasonable time and inform the member of our assessment within 10 days of finalising a claim.
Disputes
Disputes have been determined by Notices 1213 and 1214 as published in Government Gazette 33881 on 17 December 2010. The notice can be summarised as follows:
- An insurer must accept, reject, or dispute a claim within a reasonable time;
- An insurer must notify the policyholder in writing of the decision taken in paragraph (1) within 10 days of the decision;
- The notice should include:
a) Reasons for the decision
b) Option for policyholder to make representations (“dispute”) to claim within 90 days of receipt of the notice
c) Insurer must respond in writing within 45 days of receipt of this notice
i) The obligation to inform the claimant that he or she has the right to lodge a complaint to:
ii) The FAIS Ombudsman (for any complaints against an intermediary – broker, administrator or underwriting manager); and / or
iii) The ombudsman for Short-Term Insurance or Long-Term Insurance (for any complaints against the insurer) - All benefits payable shall be paid to the Principal Insured Member and not the service provider; and
- No benefit payable shall carry interest.
When will a claim (Benefit) be authorised for payment?
- Once we have confirmed validity of your policy and dependants.
- Once we confirm your premium payments are up to date.
- Once we have validated your claim using sub-contracted administrators if required.
- Once we have confirmed benefits for the claim ICD-10 Coding.
- Upon all policy conditions having been met.
- Upon confirmation of a valid HPCSA practice number.
- Once all required documents have been received.
- Depending on the benefit design of your chosen medical scheme option.
a) Hospital Plan: Benefits will be paid in the event that your option pays a portion of the claim.
b) Savings Plan: Benefits will be paid in the event that your option pays a portion of the claim. However, the value settled by the Insurer will be limited to the Gap portion after the scheme has defrayed the scheme rate of the claim provided that there was an accumulated or allocated savings balance at the time of claim.
c) Traditional medical scheme option: Benefits will be paid in the event that your option pays a portion of the claim.