GAP ULTIMATE PLUS COVER
With the addition of the GAP Ultimate Plus option, we’re able to over niche Benefits for the more Mature Members needing even More Comprehensive Cover.
Our Premium Cover is designed to provide the ULTIMATE Cover and offers a Vast Range of Benefits, per insured to cater for unforeseen Medical Expense shortfalls, up to 700% of the Medical Scheme Rate and provides Comprehensive Benefits.
In this flagship option, we cover members to the full extent of the GAP Ultimate Cover with increased limits per person and further enhanced to provide, lump sum cancer diagnosis benefits, International Travel Insurance, Cura GAP Ultimate Premium Waiver (Death or Total and Permanent Disability), and an Accidental Death Benefit.
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.
2025 CURA GAP ULTIMATE PLUS COVER
| Cover | Annual Limit | Benefit Description | |
|---|---|---|---|
| Overall Annual Limit (OAL) of R210 580 per Insured (limit subject to regulatory amendments). | |||
 | Gap Cover | No penalty shortfalls will be covered under this policy. | The shortfall that arises after your medical aid has processed your account, as a result of the service providers charging above scheme tariff for authorised in-hospital procedures. The benefit pays up to 700% of scheme tariff less the higher of the amount paid by the scheme or the scheme tariff for in-hospital procedures/treatment and certain specified out-of-hospital procedures/treatments. You must belong to a registered South African medical scheme to qualify for Gap Cover. |
| Cover for all Prescribed Minimum Benefits (PMB’s) | R210 580.00 per Insured per annum. | A set of defined benefits, as per the Medical Schemes Act, in terms of which all medical schemes must cover the costs related to the diagnosis, treatment and care of any emergency medical condition; a limited set of 270 medical conditions; and 27 chronic conditions. | |
| Out-Patient Cover | Approximately 55 listed out-patient shortfalls are covered | Day procedure performed in a Doctor’s room. | |
| Private Room Cover | R10 000 / Policy / Annum | Claim the shortfalls when the medical scheme pays part of the cost of a private hospital room. | |
 | In-hospital Co-payments / Deductibles (Includes out-of-hospital MRI and CT scans) | R210 580.00 per Insured per annum. | A co-payment or deductible is an upfront amount that needs to be paid to the hospital/day clinic/radiologist before undergoing certain procedures, as specified by your Medical Scheme. When you experience a co-payment for a procedure or scan (as specified by your Medical Scheme) you would need to pay for the co-payment up-front and then claim the amount back from your Cura Gap Policy. If your Medical Scheme pays for co-payments from your day-to-day benefits, you may still claim the amount. This benefit includes out-of-hospital MRI/CT scans. |
| Co-payment: Non-DSP Hospital | R18 000 per claim, 2 claims per policy per annum | The use of a Non-DSP hospital which results in a co-payment will be covered up to R18 000 per Insured per annum. | |
| Co-payments for Robotic-assisted Surgeries | R30 000 / Policy / Per annum | ||
| Sub-limitations | R80 000 per Insured | A benefit equal to charges above any sub-limitation imposed by the Medical Scheme for treatment received whilst as an in-patient. | |
| Co-Payment on Rheumatoid Arthritis Biological Medication | R30 000 / Policy / Annum | ||
| Specialist Consultations | R600 per Claim | Only the gap portion of the Specialist Consultation will be covered for visits up to a maximum of 4 claims per annum. Due to the lack of legislation governing what a specialist may charge for an out of hospital consultation, it has become necessary to provide a benefit where Cura assists the member with the Gap between the Specialist Consultation charged and the medical scheme rate. | |
| Shortfall on Consumables In-Hospital | R7 000 per Insured | Benefit equal to the cost of consumables not covered by the Medical Scheme for treatment received for an in-patient and/or out-patient treatment (as stated in the Defined event of the Policy Contract). Covers shortfalls on disposable items such as surgical gloves, bandages, and gauze. | |
| TTO medication shortfalls as on hospital account, paid from Scheme Risk | R500 per Claim, Subject to Consumable Limit | ||
 | Internal Prosthesis | Included in R80 000 Sub-Limit | The shortfall on a service provider account that is not covered where you have reached the sub-limit for Internal Prosthesis imposed by your medical scheme AND which has been authorised and paid from the In-Hospital or Major Medical benefit. It covers the difference in Internal prosthesis (examples include hips, knees, and spinal prosthesis, Cochlear Implants, and even cardiac pacemakers.) |
| External Prosthesis | R5 000 per Policy | The shortfall on a service provider account that is not covered where you have reached the sub-limit for External Prostheses imposed by your Medical Scheme AND which has been authorised and paid from the In-Hospital or Major Medical benefit. | |
 | Sub-limitations on Intra – Ocular Lenses | R9 000 per lens per annum | The shortfall on a service provider account that is not covered where you have reached the sub-limit for Intra-Ocular lenses imposed by your Medical Scheme AND which has been authorised and paid from the In-Hospital or Major Medical benefit. |
| External Medical Appliances | R7 500 per Policy | The shortfall on a service provider account that is not covered where you have reached the sub-limit for external appliances imposed by your Medical Scheme AND which has been authorised and paid from the In-Hospital or Major Medical benefit. Limited to CPAP machine, hearing aids, compression stockings, Mirena Device, Insulin Pump (children under 18yrs) and Glucometer (if you belong to diabetes program). The benefit only covers the Gap portion or once Medical Scheme limit has been depleted. | |
 | Radiology and Pathology Services | R14 000 per Insured | Combined capped amount where a member’s available out of hospital benefits are depleted. This benefit provides an amount of R12 000 per individual per year for Radiology done by a Radiologist or blood tests done by a Pathologist when all available day-to-day benefits have been depleted. The Radiology benefit includes sonars done by a Radiologist but excludes sonars done by a GP or Gynaecologist. |
 | Oncology treatment | OAL (R210 580) | The co-payment or deductible that your medical aid charges you or approved treatment after the higher of your oncology limit or R210 580 has been reached, including co-payments on items such as biological medication, radiotherapy, and chemotherapy per treatment cycle. |
| Benefit due to a Mastectomy on the unaffected breast | R40 000 and 1 Event / Insured / Lifetime | 1 event per person, per lifetime (subject to qualifying criteria) if there is a short payment or ex-gratia benefit given by the medical scheme (Internal Prostheses included) | |
 | Non-Listed Biological Cancer Drugs (If scheme provided a portion) | R40 000 / Policy / Annum. | |
 | Dental procedures | R10 000 per Insured | The cost of emergency medical treatment or a surgical procedure due to accidental impact resulting in severe physical injury or due to cancer. Implants are not included as part of this benefit. |
| Dental procedures shortfalls | R50 000 per policy | Due to cancer. Implants are included. | |
 | Casualty Benefit | R15 000 per Insured | The cost of emergency medical treatment or a surgical procedure performed in the hospital casualty unit, should such cost not be covered by the Medical Scheme. Emergency Triage Index applies. (Include: Orange and Red triage). This excludes medical appliances such as crutches, braces, wheelchairs, and take-home medication.“Emergency” means the sudden and unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or death. The determination of an Emergency will be done through diagnosis (through classification by the attending Medical Practitioner and / or the Casualty Unit) and not on symptoms presented. Emergency Triage Index applies (Orange and red triage). |
 | Trauma Counselling | R10 000 per Insured | This benefit covers counselling sessions with a registered counsellor or clinical psychologist that may be required after a serious or traumatic event. Insured must receive counselling within (1) one year of trauma incident. |
| Additional Care Cover | R12 000 per Insured | Covers stay at a registered sub-acute or step-down facility for rehabilitation treatment, including therapy provided by on-site therapists (Sub-limit per policy and once Medical Scheme benefit limits are depleted). Includes registered Sub-Acute facilities such as Step-down (where the member needs the level of care which he/she would receive in hospital but does not need to be hospitalised) or rehabilitation facilities when a member needs to be rehabilitated after surgery. | |
| THE FOLLOWING BENEFITS ARE NOT SUBJECT TO THE ANNUAL AGGREGATE LIMIT OF R210 580 PER INSURED PER ANNUM | |||
| First Time Cancer Lump Sum Benefit | Once-Off R30 000 per Insured | This benefit will provide a lump sum amount in the event of Stage 1 Cancer and higher. The benefit excludes pre-existing Cancer and Skin Cancer. |
| Accidental Death Benefit | R15 000 per Insured | Must meet the definition of Accidental. |
| Premature Birth | R5 000 per Policy | This benefit will provide a lump sum amount in the event of a premature birth (Birth between 24 – 34 weeks of pregnancy) of the Principal Member or spouse. | |
| International Medical Travel Cover | R5 million per Insured | Maximum of 90 days per trip. Maximum age is 80 years at next birthday. | |
 | 12 Months Medical Scheme Premium Waiver | No Maximum per month | This benefit will cover the monthly premium due to your Medical Scheme in the event of the accidental death and permanent disability of the Principal Member as a result of an accident for a period of 12-months. |
| Gap Premium Waiver | 12 Months | This benefit will cover the monthly premium of your Gap Cover in the event of the accidental death and permanent disability of the Principal Member as a result of an accident for a period of 12-months. | |
2025 CURA GAP ULTIMATE PLUS COVER
| Cover | Annual Limit | Benefit Description | |
|---|---|---|---|
| Overall Annual Limit (OAL) of R210 580 per Insured (limit subject to regulatory amendments). | |||
| Gap Cover | No penalty shortfalls will be covered under this policy. | The shortfall that arises after your medical aid has processed your account, as a result of the service providers charging above scheme tariff for authorised in-hospital procedures. The benefit pays up to 700% of scheme tariff less the higher of the amount paid by the scheme or the scheme tariff for in-hospital procedures/treatment and certain specified out-of-hospital procedures/treatments. You must belong to a registered South African medical scheme to qualify for Gap Cover. |
| Cover for all Prescribed Minimum Benefits (PMB’s) | R210 580.00 per Insured per annum. | A set of defined benefits, as per the Medical Schemes Act, in terms of which all medical schemes must cover the costs related to the diagnosis, treatment and care of any emergency medical condition; a limited set of 270 medical conditions; and 27 chronic conditions. | |
| Out-Patient Cover | Approximately 55 listed out-patient shortfalls are covered | Day procedure performed in a Doctor’s room. | |
| Private Room Cover | R10 000 / Policy / Annum | Claim the shortfalls when the medical scheme pays part of the cost of a private hospital room. | |
| In-hospital Co-payments / Deductibles (Includes out-of-hospital MRI and CT scans) | R210 580.00 per Insured per annum. | A co-payment or deductible is an upfront amount that needs to be paid to the hospital/day clinic/radiologist before undergoing certain procedures, as specified by your Medical Scheme. When you experience a co-payment for a procedure or scan (as specified by your Medical Scheme) you would need to pay for the co-payment up-front and then claim the amount back from your Cura Gap Policy. If your Medical Scheme pays for co-payments from your day-to-day benefits, you may still claim the amount. This benefit includes out-of-hospital MRI/CT scans. |
| Co-payment: Non-DSP Hospital | R18 000 per claim, 2 claims per policy per annum | The use of a Non-DSP hospital which results in a co-payment will be covered up to R18 000 per Insured per annum. | |
| Co-payments for Robotic-assisted Surgeries | R30 000 / Policy / Per annum | ||
| Sub-limitations | R80 000 per Insured | A benefit equal to charges above any sub-limitation imposed by the Medical Scheme for treatment received whilst as an in-patient. | |
| Co-Payment on Rheumatoid Arthritis Biological Medication | R30 000 / Policy / Annum | ||
| Specialist Consultations | R600 per Claim | Only the gap portion of the Specialist Consultation will be covered for visits up to a maximum of 4 claims per annum. Due to the lack of legislation governing what a specialist may charge for an out of hospital consultation, it has become necessary to provide a benefit where Cura assists the member with the Gap between the Specialist Consultation charged and the medical scheme rate. | |
| Shortfall on Consumables In-Hospital | R7 000 per Insured | Benefit equal to the cost of consumables not covered by the Medical Scheme for treatment received for an in-patient and/or out-patient treatment (as stated in the Defined event of the Policy Contract). Covers shortfalls on disposable items such as surgical gloves, bandages, and gauze. | |
| TTO medication shortfalls as on hospital account, paid from Scheme Risk | R500 per Claim, Subject to Consumable Limit | ||
| Internal Prosthesis | Included in R80 000 Sub-Limit | The shortfall on a service provider account that is not covered where you have reached the sub-limit for Internal Prosthesis imposed by your medical scheme AND which has been authorised and paid from the In-Hospital or Major Medical benefit. It covers the difference in Internal prosthesis (examples include hips, knees, and spinal prosthesis, Cochlear Implants, and even cardiac pacemakers.) |
| External Prosthesis | R5 000 per Policy | The shortfall on a service provider account that is not covered where you have reached the sub-limit for External Prostheses imposed by your Medical Scheme AND which has been authorised and paid from the In-Hospital or Major Medical benefit. | |
| Sub-limitations on Intra – Ocular Lenses | R9 000 per lens per annum | The shortfall on a service provider account that is not covered where you have reached the sub-limit for Intra-Ocular lenses imposed by your Medical Scheme AND which has been authorised and paid from the In-Hospital or Major Medical benefit. |
| External Medical Appliances | R7 500 per Policy | The shortfall on a service provider account that is not covered where you have reached the sub-limit for external appliances imposed by your Medical Scheme AND which has been authorised and paid from the In-Hospital or Major Medical benefit. Limited to CPAP machine, hearing aids, compression stockings, Mirena Device, Insulin Pump (children under 18yrs) and Glucometer (if you belong to diabetes program). The benefit only covers the Gap portion or once Medical Scheme limit has been depleted. | |
| Radiology and Pathology Services | R14 000 per Insured | Combined capped amount where a member’s available out of hospital benefits are depleted. This benefit provides an amount of R12 000 per individual per year for Radiology done by a Radiologist or blood tests done by a Pathologist when all available day-to-day benefits have been depleted. The Radiology benefit includes sonars done by a Radiologist but excludes sonars done by a GP or Gynaecologist. |
| Oncology treatment | OAL (R210 580) | The co-payment or deductible that your medical aid charges you or approved treatment after the higher of your oncology limit or R210 580 has been reached, including co-payments on items such as biological medication, radiotherapy, and chemotherapy per treatment cycle. |
| Benefit due to a Mastectomy on the unaffected breast | R40 000 and 1 Event / Insured / Lifetime | 1 event per person, per lifetime (subject to qualifying criteria) if there is a short payment or ex-gratia benefit given by the medical scheme (Internal Prostheses included) | |
| Non-Listed Biological Cancer Drugs (If scheme provided a portion) | R40 000 / Policy / Annum. | |
| Dental procedures | R10 000 per Insured | The cost of emergency medical treatment or a surgical procedure due to accidental impact resulting in severe physical injury or due to cancer. Implants are not included as part of this benefit. |
| Dental procedures shortfalls | R50 000 per policy | Due to cancer. Implants are included. | |
| Casualty Benefit | R15 000 per Insured | The cost of emergency medical treatment or a surgical procedure performed in the hospital casualty unit, should such cost not be covered by the Medical Scheme. Emergency Triage Index applies. (Include: Orange and Red triage). This excludes medical appliances such as crutches, braces, wheelchairs, and take-home medication.“Emergency” means the sudden and unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or death. The determination of an Emergency will be done through diagnosis (through classification by the attending Medical Practitioner and / or the Casualty Unit) and not on symptoms presented. Emergency Triage Index applies (Orange and red triage). |
| Trauma Counselling | R10 000 per Insured | This benefit covers counselling sessions with a registered counsellor or clinical psychologist that may be required after a serious or traumatic event. Insured must receive counselling within (1) one year of trauma incident. |
| Additional Care Cover | R12 000 per Insured | Covers stay at a registered sub-acute or step-down facility for rehabilitation treatment, including therapy provided by on-site therapists (Sub-limit per policy and once Medical Scheme benefit limits are depleted). Includes registered Sub-Acute facilities such as Step-down (where the member needs the level of care which he/she would receive in hospital but does not need to be hospitalised) or rehabilitation facilities when a member needs to be rehabilitated after surgery. | |
| THE FOLLOWING BENEFITS ARE NOT SUBJECT TO THE ANNUAL AGGREGATE LIMIT OF R210 580 PER INSURED PER ANNUM | |||
| First Time Cancer Lump Sum Benefit | Once-Off R30 000 per Insured | This benefit will provide a lump sum amount in the event of Stage 1 Cancer and higher. The benefit excludes pre-existing Cancer and Skin Cancer. |
| Accidental Death Benefit | R15 000 per Insured | Must meet the definition of Accidental. |
| Premature Birth | R5 000 per Policy | This benefit will provide a lump sum amount in the event of a premature birth (Birth between 24 – 34 weeks of pregnancy) of the Principal Member or spouse. | |
| International Medical Travel Cover | R5 million per Insured | Maximum of 90 days per trip. Maximum age is 80 years at next birthday. | |
| 12 Months Medical Scheme Premium Waiver | No Maximum per month | This benefit will cover the monthly premium due to your Medical Scheme in the event of the accidental death and permanent disability of the Principal Member as a result of an accident for a period of 12-months. |
| Gap Premium Waiver | 12 Months | This benefit will cover the monthly premium of your Gap Cover in the event of the accidental death and permanent disability of the Principal Member as a result of an accident for a period of 12-months. | |
What does Cura Administrators GAP Ultimate Plus Cover entail?
Waiting Periods Applicable:
- 3-month general waiting period.
- 12-month waiting period for pre-existing conditions.
- 9-months waiting period on pregnancy (if pregnant with inception)
Concessions on the above waiting periods will be considered for group schemes.
Maximum Entry Age:
No Maximum entry age is applicable to this policy.
Child dependants are covered until they reach the age of 21 years, with the option to continue cover as a principal insured and no new underwriting or waiting periods will apply.
This age may be extended up to 27 (twenty-seven) in respect of an unmarried child who is financially dependent on the Principal Insured Person, is not employed, is covered under the Principal Insured Person’s medical scheme (Affidavit for above will be required) and/or is a full-time student at a recognised institute.
All newborns must be registered on this policy within 30 days after birth.
Monthly Premium:
| Entry Age | Monthly Premium |
|---|---|
| Individual < 64 years | R750.00 per month |
| Family < 64 years | R905.00 per month |
| Individual > 65 years | R905.00 per month |
| Family > 65 years | R1190.00 per month |
Premiums (incl. VAT) are for a single person. Premiums are reviewed and may be adjusted annually.
Terms and conditions apply in terms of exclusions and claim procedures.
CURA GAP ULTIMATE PLUS COVER EXCLUSIONS
The Product Provider shall not be liable for costs incurred for hospitalisation, bodily injury, sickness, or related disease directly or indirectly because of or in consequence of:
- Exposure to discharged nuclear weaponry fallout or by ionising radiation or contamination by radio activity from any nuclear matter or from any nuclear waste from the combustion of nuclear fuel. For this exception, combustion shall include any self-sustaining process of nuclear fission.
- Suicide, attempted suicide, or intentional self-injury.
- Consuming any drug or narcotic unless prescribed by and taken in accordance with the instructions of a registered medical practitioner (other than the insured
person). - Drug Addiction.
- An event directly attributable to the insured person having a blood alcohol concentration exceeding the legal permitted level, or the insured person presenting with alcoholism or an illness resulting from alcohol abuse.
- Hospital accommodation
- Participation in:
- Active military duty, police duty, police reservist duty (only applicable to Gap Cover and short-term products), civil commotion, labour disturbances, riot, strike, or the activities of locked out workers).
- Aviation other than as a passenger (excl. commercial pilots).
- Any form of race or speed test, other than on foot or non-mechanically propelled vehicle, vessel, craft, or aircraft.
- Any procedure not covered or declined by the medical scheme.
- No benefits shall be payable for an insured event for which the insured person received treatment or advice 12 months prior to becoming an insured person. This exclusion applies to the first 12 months of cover only.
- No benefits shall be payable for pregnancy or childbirth for a period of 9 months from inception of the policy.
- Investigations, treatment or surgery for artificial insemination or hormone treatment for infertility.
- Depression, insanity or mental stress or psychotic/psychoneurotic disorders.
- No benefits shall be payable in the event of fraudulent claim submission.
The table of benefits do not apply to any territory outside of the borders of the Republic of South Africa, Botswana, Lesotho, Swaziland, Namibia, Zimbabwe, and Mozambique.