Focus on Momentum GapCover 2025

Below is information about Momentum GapCover+

Have you ever considered the financial implications of potential shortfalls associated with in-hospital procedures and other healthcare expenses that may not be covered by your medical scheme option? With Momentum GapCover, you can alleviate these concerns. Momentum GapCover provides supplementary coverage designed to assist with any shortfalls that may arise during hospitalization for surgical or medical treatments. This coverage extends to certain procedures that take place out-of-hospital or in day clinics, provided you have obtained the necessary authorization. You have the option to select between the more budget-friendly GapCover Primary or the comprehensive benefits offered by GapCover Supreme, allowing you to choose a plan that best fits your needs.

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 costs

This benefit covers the difference between the fees charged by medical practitioners and the amount reimbursed by your medical scheme, up to three times the amount paid by the medical scheme. Additionally, Momentum GapCover Supreme extends coverage for certain medical procedures conducted outside of a hospital setting, such as those performed in day clinics or other registered facilities. These shortfalls are similarly covered up to three times the amount reimbursed by the medical scheme. Depending on your chosen option, your total coverage will be as follows:

• Ingwe, Custom, and Evolve Options: 400% of the Momentum Medical Scheme Rate
• Incentive and Extender Options: 800% of the Momentum Medical Scheme Rate
• Summit Option: 1,200% of the Momentum Medical Scheme Rate

Allied professionals

This benefit covers the shortfall between what allied professionals charge and what the Momentum Medical Scheme pays for in-hospital care following a related in-hospital procedure. Coverage is provided up to three times the amount reimbursed by the Momentum Medical Scheme, with a limit of R2,500 per policy per year. A detailed list of the allied professionals covered can be found on page 6 of the policy document.

Co-payments

This benefit addresses co-payments that your medical scheme may apply for hospital admissions, procedures, and certain day clinic treatments. However, it is important to note that this benefit does not cover co-payments incurred due to the voluntary use of non-Designated Service Providers.

Co-payments on oncology treatment

This provision covers the 20% co-payment that is applied to oncology treatment once the medical scheme limit has been reached, ensuring that you are not left with a significant financial burden during a challenging time.

Robotic procedure shortfall benefit

In cases where your medical condition necessitates robotic-assisted surgery, this benefit will cover the shortfall related to the fees charged by the medical practitioners performing the surgery, up to three times the amount reimbursed by your medical scheme.

Robotic procedure co-payment benefit

If your medical scheme requires a co-payment for robotic-assisted surgery, this benefit will cover you up to R12,000 per policy per year, helping to ease the financial impact of this advanced medical procedure.

Casualty benefit

Should you visit a casualty ward within 24 hours of an emergency resulting from an accident, this benefit will pay up to R24,000 for all incurred costs. This benefit is limited to five casualty visits per family per year. Furthermore, three of these visits, capped at R5,000 per policy per year, may be utilized in emergencies (regardless of whether they were accident-related) for children aged eight years or younger. The costs associated with these three visits will count towards the R24,000 annual limit.

Internal prosthesis benefit

This benefit covers shortfalls related to internal prosthesis costs, with a maximum coverage of R35,000 per policy per year. Stents and pacemakers are specifically covered up to a sub-limit of R8,000 per claim event, which is still 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 receive a first-time diagnosis of minimum stage 2, local and malignant cancer, we will provide you with a payment of R8,000. In cases where you are diagnosed with minimum stage 2, regional and malignant cancer, the payout will increase to R20,000. If, following the R20,000 benefit, your medical scheme covers more than R200,000 for your oncology treatment within 12 months of your diagnosis, we will provide an additional R15,000. This benefit is available once in a lifetime for each person covered under the policy.

Breast reconstruction benefit for non-affected breast

If you are diagnosed with breast cancer and require cosmetic breast reconstruction for the non-affected breast following a mastectomy, we will provide coverage of R15,000 per policy per year. This financial assistance can be utilized to recover costs associated with the treatment or related expenses.

Accident assist benefit

This benefit provides a payout of R55,000 in the event of death or permanent disability due to an accident. It is important to note that this is subject to a limit of one claim per insured individual per lifetime.

Violent crime benefit

If you or a dependent successfully claims the Accident Assist benefit and the claim event was a result of a violent crime, we will double the payout to R110,000, providing additional support during a difficult time.

Premium waiver benefit

In the unfortunate event that you or a dependent responsible for paying the monthly premium on this policy passes away or becomes permanently and totally disabled due to an accident while covered under this policy, we will assist your dependents by covering the cost of their monthly medical scheme contributions and gap cover premiums with an upfront payment of R36,000.

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), experience a traumatic accident, or suffer the loss of an immediate family member, we will pay you a fixed amount of R800 per session for trauma counselling fees, with a limit of R30,000 per policy per year.

Baby bump benefit

If you become pregnant while covered under the policy, we will provide you with an upfront payment of R2,500 to assist with any unexpected costs that may arise during your pregnancy.

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 be aware that applications for Momentum GapCover are only accepted if you are a member of the Momentum Medical Scheme. The rates listed are per policy per month. The age group specified applies to the principal member, and no dependents may be added to Momentum GapCover if the principal insured is over the age of 65 or if they are under 30.

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 costs

This benefit functions similarly to the Supreme option, covering the difference between the fees charged by medical practitioners and the amount reimbursed by your medical scheme, up to three times the amount paid by the medical scheme. Momentum GapCover Primary also extends coverage for certain medical procedures conducted outside of hospitals, such as those performed in day clinics or other registered facilities, with similar shortfall coverage.

Depending on your selected option, the total coverage will be as follows:

• Ingwe, Custom, and Evolve Options: 400% of the Momentum Medical Scheme Rate
• Incentive and Extender Options: 800% of the Momentum Medical Scheme Rate
• Summit Option: 1,200% of the Momentum Medical Scheme Rate

Co-payments

This benefit addresses co-payments applied by the medical scheme for hospital admissions, procedures, and certain day clinic treatments. As with the Supreme option, it does not cover co-payments incurred due to the 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 cover up to R12,000 of all costs incurred. This benefit is limited to five casualty visits per family per year. Additionally, three of these visits, capped at R2,500 per policy per year, may be utilized in emergencies (regardless of the cause) for children aged eight years or younger. The costs associated with these three visits will count toward the R12,000 annual limit.

Momentum GapCover Primary premiums

Momentum GapCover Primary <42 – Family

R385

Momentum GapCover Primary <42 – Single

R358

Momentum GapCover Primary 42 – Family

R549

Momentum GapCover Primary 42 – Single

R498

Please note that applications for Momentum GapCover are only accepted if you are a member of the Momentum Medical Scheme. The rates listed are per policy per month, and the age group specified applies to the principal insured. Momentum GapCover Primary is not available to principal members who are under 30 or over 65.

Quotes for employer groups

For groups of more than 20 members who are not covered by another gap provider, premiums will be calculated based on the demographics of the group. This includes considerations such as the average age of the group, the total number of members, and whether membership is voluntary or compulsory. If the group consists of more than 20 members but is already covered by another gap provider, we will require a minimum of three years’ loss ratio or average claim spend per member per month to provide an accurate quote.

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 individual 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 individual 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

For 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

Claiming for Momentum GapCover shortfall benefits is a streamlined process. Our system automatically identifies any potential GapCover claims without requiring you to fill out a claim form or submit documentation. We will notify you of any potential claims and subsequently inform you of the claim's outcome. This seamless claims process applies to the following claims:

• Shortfall for medical practitioners for in-hospital procedures (available for both Supreme and Primary options)
• Co-payments (available for both Supreme and Primary options)
• Oncology co-payments (available for Supreme option only)
• Internal prosthesis claims (available for Supreme option only)
• Casualty benefit claims (available for both Supreme and Primary options)
• Baby bump benefit claims (available for Supreme option only)

If you are claiming for any of the following Assist benefits on the Supreme option, you will need to submit a claim form to provide us with additional information:

• Cancer assist pay-out for cancer diagnosis
• Accidental death or disability
• Violent crime
• Premium waiver
• Trauma and bereavement counselling

Out-of-hospital/day clinic procedures we cover

We provide coverage for a variety of out-of-hospital/day clinic procedures, including:

• Urology: Circumcision (when medically necessary), 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
• Renal: Kidney dialysis

Allied professionals that we cover

We also provide coverage for services rendered by various allied professionals, including:

• Chiropractors
• Clinical technologists
• Genetic counselors
• Myotherapists
• Occupational therapists
• Orthoptists
• Osteopaths
• Perfusionists
• Physiotherapists
• Podiatrists
• Speech pathologists

What we do not cover

There are certain expenses that are not covered under the medical expense shortfall benefit, including:

• Shortfalls where your medical scheme has not paid the initial portion of the costs
• Hospital and day clinic fees, including theatre charges, ward charges, or any other related costs
• Pre-admission or out-of-hospital consultation costs
• Materials or medications used during a procedure
• Dental implants
• Appliances such as wheelchairs, crutches, braces, etc.
• Out-of-hospital dental procedures
• Home and private nursing services
• Cosmetic procedures
• Exploratory procedures such as blood tests, pap smears, ultrasounds, etc.
• Procedures paid for by your medical scheme on an exception or ex-gratia basis
• Weight loss treatments specifically for obesity
• Costs directly related to the patient's Body Mass Index (BMI) or weight
• Hospice or step-down facilities
• Annual or routine medical examinations
• Mental health disorders such as anxiety, mood disorders, psychotic disorders, dementias, and eating disorders
• Transportation costs for emergency vehicles or aircraft, as well as emergency medical service charges
• Auxiliary or para-medical services, including speech therapists, audiologists, physiotherapists, etc.

Co-payment benefit

The following co-payments are not covered:

• Co-payments applied for using a non-Designated Service Provider (non-DSP)
• Co-payments incurred due to not adhering to the medical scheme's protocols (e.g., not being referred to a specialist by a GP, not obtaining pre-authorization for a procedure, etc.)
• Co-payments for private ward usage or other special requests not covered by your medical scheme
• Co-payments related to conditions for which you are currently in a waiting period

Oncology co-payment benefit

This benefit does not cover co-payments incurred for treatment with a non-Designated Service Provider.

Internal prosthesis shortfall benefit

The following shortfalls are not covered:

• Shortfalls where your medical scheme has not paid the initial portion of costs
• External prostheses or dental implants

Casualty benefit

The casualty benefit does not cover:

• Elective procedures performed 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, except for the medical practitioner costs, are not covered.

Robotic procedure co-payment benefit

Any amount exceeding the R12,000 annual cap is not covered.

Benefit for first-time cancer diagnosis

The following are not covered under this benefit:

• Any diagnosis that does not meet the minimum criteria for eligibility
• Any diagnosis that is not a first-time diagnosis
• All skin cancers

Benefit for accidental death or accidental permanent and total disablement

This benefit does not cover:

• Death or permanent and total disablement not directly caused by an accident as defined in the policy
• Disability that is not classified as total and permanent as defined in the policy

Premium waiver benefit for accidental death or accidental permanent and total disablement due to an accident

This benefit does not cover:

• Death or permanent and total disablement not directly caused by an accident as defined in the policy
• Disability that is not classified as total and permanent as defined in the policy

Benefit for trauma or bereavement counselling

The following are not covered:

• Any counselling not related to an act of violence or a traumatic accident
• Any counselling not conducted by a counselor 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 does not meet the specific criteria outlined in the policy is not covered.

General exclusions

Claims arising from the following events are not covered:

• Participation in war, invasion, terrorist activity, rebellion, active military duty, police duty, police reservist duty, civil commotion, labor disturbances, riot, strike, or activities of locked-out workers
• Nuclear weapons, nuclear material, ionizing radiation, or contamination by radioactivity from any nuclear fuel or waste from nuclear fuel combustion, including self-sustaining nuclear fission processes
• Use of any legal drug unless prescribed by a registered medical practitioner and taken in accordance with their instructions
• Use of any illegal drug
• Engagement in illegal activities or violations of South African law
• Suicide, attempted suicide, intentional self-injury, or any form of exposure to danger
• Aviation activities, except as a fare-paying passenger on a commercial flight
• Participation in professional sports, where you are compensated for your participation
• Engagement in hazardous sports, including hang-gliding, kite-surfing, mountaineering, paragliding, scuba diving, and skiing
• Participation in any race or speed test, except on foot or using non-mechanically propelled vehicles, vessels, or aircraft.

Terms and conditions of cover

All benefits offered are subject to the terms and conditions outlined in the policy. A comprehensive description of these terms and conditions, along with the exclusions, is available upon request or in the policy document.

This information is protected by applicable intellectual property laws and may not be copied, distributed, or modified for commercial purposes. Although every effort has been made to ensure the information provided is current, fair, and accurate, we cannot guarantee its completeness. The use of this information by any third party is at their own discretion and is provided for factual purposes only. The information contained herein, including client endorsements, does not constitute financial advice as defined by the Financial Advisory and Intermediary Services Act 2002. Guardrisk Insurance Company Limited does not expressly or implicitly endorse or recommend that the products or services mentioned are suitable for the specific needs of any third party. Furthermore, Guardrisk Insurance Company Limited does not accept liability for any loss, damage, costs, or expenses incurred directly or indirectly as a result of any errors or omissions in this document.

It is important to note that Momentum GapCover is not a medical scheme, and its coverage is not equivalent to that of a medical scheme. This product is not intended to serve as a substitute for medical scheme membership.

+You may choose to utilize additional products available from Momentum Group Limited and its subsidiaries, as well as Momentum Multiply (collectively referred to as Momentum). Momentum is not a medical scheme and operates independently from Momentum Medical Scheme. Products offered by Momentum are not considered medical scheme benefits. You may be a member of Momentum Medical Scheme without subscribing to any of the products provided by Momentum.