The Liberty Gap insurance policy provides coverage for medical aid shortfalls of up to R182,700.00 per member. Premiums for Liberty gap cover start at R333.00 per person, a month and can go up to R650.00 per person a month.
The Liberty gap cover offers two options for covering the main member of the medical aid and their dependents. The options for Liberty gap medical coverage are further discussed below.
The Liberty Medical Gap Cover offers universal gap cover and essential gap cover. Each cover is explained in detail as follows:
The Liberty universal gap insurance policy provides comprehensive medical expense shortfall coverage as well as additional financial protection for various health risks.
Individuals can choose between individual cover, which is available to those who do not have a medical scheme, and family cover, which is available to those who have dependents on their medical scheme.
Each family member is covered for medical expense shortfalls up to R182,700.00 per year. The medical shortfalls covered by the Liberty universal gap cover include:
In-hospital medical expenses are covered up to 500% of the medical scheme tariff on doctors’ and specialists’ fees. The cover is limited to the medical expense shortfall limit of R182,700.00 if no other claims are made.
The Liberty universal gap cover covers out-of-hospital medical expenses for 50 outpatient procedures, including CT, PET, and MRI scans.
Other procedures and medications may require co-payments under the Medical Scheme, and the Liberty universal gap cover covers co-payments when they are due. Penalty co-payments charged by the medical scheme are not covered. Co-payments that are not covered include penalties imposed by medical plans for failing to see a general practitioner before consulting with a specialist, for example.
The non-network co-payments cover provides full coverage for co-payments charged by medical schemes for using a hospital or provider that is not on a network of hospitals as identified by a medical scheme. The coverage is limited to a maximum of R11,000.00 per claim per policy per year.
The casualty ward cover covers the cost of a stay in a casualty ward. This policy covers accidental injury for treatment in a hospital casualty ward within 48 hours of the accident. The cover for the casualty ward is limited to R22,000.00 per calendar year.
Once the sub-limit for MRI, PET, or CT scans is reached, the benefit pays in part or in full for the cost of the scans. Each insured person covered by the plan is entitled to a maximum of R3,000.00 per calendar year.
When the annual cancer treatment limit is exceeded, co-payments imposed by medical plans will be covered. This coverage is available for both general and specialized treatment, as well as biological drugs, with a maximum co-payment of 25% of the treatment costs.
When a medical plan imposes a cancer treatment cost limit, coverage for 20% of the ongoing treatment costs is provided. This coverage is applicable to both general and specialized treatment, as well as biological drugs.
This benefit provides coverage for cosmetic breast reconstruction of up to R23,000. In the event of a single mastectomy due to breast cancer, this coverage will pay for the costs of surgical breast reconstruction of the non-affected breast.
Medical expense shortfalls and co-payments on the cost of internal prosthesis are covered up to R37,000 per policy per calendar year. This benefit is available to policyholders with medical scheme options that include internal prosthesis coverage as part of the major medical benefit.
This benefit covers the difference if the medical scheme does not cover the full cost of internal prosthesis because the annual limit has been reached or if the medical scheme charges a co-payment.
Shortfalls in dentistry expenses are covered on doctor, dentist, and specialist fees of up to 500% of the Medical Scheme Tariff (MST). The amount of shortfall cover provided is calculated as follows: doctors’ and specialists’ fees (limited to 5 times MST) less the greater of the medical scheme’s contribution to these costs or the MST.
This cover pays up to R31,500 per policy, per calendar year, for medical expense shortfalls resulting from the use of robotic machinery during in-hospital operative treatment.
The R30,000 Enhanced Cancer Cover benefit is intended to cover any unexpected costs that may arise in the event of a first-time cancer diagnosis, stage II and above. This benefit is also available for stage I prostate cancer with a Gleason score of 8 or higher.
Payment of this benefit is contingent on a confirmed cancer diagnosis with an ICD 10 C code, and the person insured under the policy enrolling in their medical scheme’s oncology treatment program. This coverage excludes skin cancer and only applies to cancer diagnoses for the first time after the start of coverage and after the 12-month waiting period.
A total of R21,200 is available for accidental tooth fracture caused by an external blow to the mouth. This benefit applies to permanent teeth (excluding crowns and implants) where at least 50% of the visible portion of the tooth is lost, and the dental nerve is permanently damaged as a result of an accident. This benefit is payable at a rate of R3,000 per fractured tooth, regardless of medical scheme coverage.
The Accidental Death and Permanent Disability Cover of R50,000 is intended to cover any unexpected costs that may arise in the event of accidental death or permanent disability of anyone covered by the policy. Accidental permanent disability coverage ends at the age of 65 for all lives insured under the policy.
Following any individual insured under the policy being subjected to or witnessing an act of violence or a traumatic accident, R750 per session of counseling is provided. Counseling must start within six months of the traumatic event and is limited to a maximum of R25,000 over a six-month period.
To cover the cost or loss incurred as a result of the policyholder’s accidental death or accidental permanent disability, a benefit equal to 12 times the policyholder’s combined monthly gap policy premium and medical scheme premium will be paid under this cover. This benefit is subject to a R105,000 policy limit. This benefit is no longer available after the age of 65.
The Liberty Gap Cover is one of the few gap cover plans that provides more than one subscription option in South Africa. The Universal Cover, which is a premium addition to the options, caters to additional treatments that most gap covers don’t. Choosing this gap cover can benefit anyone on medical aid in a variety of ways, making the cover appealing.
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