The PPS Gap Cover compensates for any shortfall in medical aid expenses. Premiums for the PPS Gap Cover amount start from R407.00 per month for the primary member who is under the age of 55.

Individuals between the ages of 55 and 64 pay a monthly premium of R504.00, while individuals over the age of 65 pay the highest premium for gap cover, with a monthly premium of R633.00.

If a family member is on medical aid, they can also be covered under the plan. Family members under the age of 65 pay a monthly premium of R504.00, while those aged 65 and over pay a monthly fixed premium of R633.00.

The PPS Gap Cover provides in-hospital and out-of-hospital coverage, and the amount covered is determined by the shortfall amount. The medical shortfalls covered by PPS Gap Cover are detailed below.

Expenses Covered by the PPS Gap Cover

The PPS Gap Cover plan covers a number of conditions. The plan covers medical expense shortfalls and includes enhanced cancer coverage. The following is an outlook on the PPS Gap medical cover.

Medical Expense Cover

The plan covers a variety of medical expenses, and the medical expenses covered in this section have a combined maximum cover limit of R192,000.00 per insured individual per calendar year. The following are some examples of medical expense shortfalls:

In-hospital Cover

The plan covers in-hospital expenses and provides coverage for doctor and specialist charges of up to 500% of the medical scheme tariff. The gap cover pays if there is a shortfall on a medical aid plan.

Medical Aid Co-payment Cover

The gap cover covers co-payments that are specified on medical aid. The policy pays for hospitalizations, scans, and medical procedures. Co-payments for penalties are not covered by the plan and must be paid by the policyholder.

Non-Network Co-payment Cover

The PPS Gap Coverage covers non-network co-payments. This enables those who have an excess when visiting a non-network hospital to use that hospital. The maximum payment for non-network co-payment coverage is R11,600.00, and it is limited to one claim per policy per year.

Accidental Injury Cover

Accidental injury treatment is covered under the plan. The plan pays a maximum of R22,100.00 for treatment in a hospital casualty ward. This benefit is available within 48 hours of an accidental injury.

The plan covers the fitting and cost of prostheses and devices such as crutches, neck braces, knee, and ankle guards. There is a maximum claim amount of R2,500.00 per policy per year.

The plan does not cover prescribed medication used after leaving the casualty facility, follow-up treatment, fitment fees, or the cost of prosthetic devices such as limb guards.

Oncology Treatment

The gap cover provides coverage for copayment treatment in excess of the cancer limit, with a maximum copayment of 25% of the costs of treatment. The coverage includes general and specialized cancer treatment, as well as biological drugs.

Coverage for ongoing cancer treatment costs is provided when a medical aid treatment cost limit is imposed and no additional funding is provided by the medical aid. The policy covers 20% of the insured’s ongoing treatment costs.

Cancer coverage is also expanded to include cosmetic breast reconstruction. The benefit has a maximum payout of R24,000.00 for each insured person.

Dental shortfall cover

The gap cover provides coverage for dentistry shortfalls for dentists and specialists charging up to 500% of the medical scheme tariff. Dental hospital admissions and procedures are covered subject to a maximum of R11,600.00 and limited to one claim per policy each year.

Out-of-hospital cover

The benefit provides cover for shortfalls in doctor and specialist out-of-hospital treatment charges. The benefit covers more than 50 procedures, and the amount covered is the specialist charges up to the medical aid tariff less greater than either of the medical aid’s payment.

Enhanced Cancer Cover

The enhanced cancer cover is an extended cancer benefit that covers unexpected costs for up to R30,000.00 and covers costs that may arise from a first-time cancer diagnosis of stage 2 and above.

This benefit applies to first-time diagnoses of stage II regional cancer and 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 (International Classification of Diseases Code) and the person insured under the policy enrolling in their medical aid’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 has passed.

Extended Cancer Cover (Optional Benefit)

The policyholder and dependents insured under the policy are covered for cancer diagnosis under the extended cancer cover. The benefit is either R100,000 or R200,000.00, depending on the policy purchased.

For the first 12 months of the plan, pre-existing conditions are not covered. The policy is valid until the policyholder reaches the age of 65. The premium for a R100,000 cover is R92.00, while the premium for an R200,000.00 cover is R150.00.

Advantages of PPS Gap Cover

• The premium amounts are very reasonable when compared to the coverage provided by the gap insurance.
• Additional family members can be added to the gap insurance policy.
• Cancer treatment and diagnosis are well covered.
• The majority of medical conditions are covered by in-hospital treatment.
• Out-of-hospital expenses are covered to a certain extent. Individuals over the age of 65 are eligible for coverage under the product.
• The plan covers both network and non-network copayments.
• Cancer-related prosthetics and cosmetic surgery are covered.

Disadvantages of PPS Gap Cover

• Premiums can be very high if other dependents are added to the plan.
• Out-of-hospital dental procedures are not covered by the plan.

Conclusion

PPS Gap Cover can accommodate many people on medical aid. The plan offers extended coverage on top of a medical aid benefit for a fraction of the cost of a medical aid premium. This product is ideal for people who want to improve their medical aid plan while also having their copayments and other medical expenses covered.