Focus on Momentum GapCover

Below is information about focus on Momentum GapCover

Momentum GapCover+

This insurance product is underwritten by Guardrisk Insurance Company Limited, which is recognized as an authorized Financial Service Provider and a licensed non-life insurer, operating under FSP No. 75.

Why should you be concerned about potential financial shortfalls related to in-hospital procedures and other healthcare expenses that your medical scheme might not cover? With Momentum GapCover, you can alleviate these worries. This supplementary insurance is designed to assist you with any financial shortfalls that may arise during hospitalization for surgery or medical treatment. It also extends coverage for certain procedures that take place outside of a hospital setting or in day clinics, provided that you have secured the necessary authorizations beforehand.

It is important to note that Momentum GapCover is not classified as a medical scheme, and its coverage differs from that of a traditional medical scheme. Therefore, this product should not be viewed as a replacement for medical scheme membership.

Shortfall benefits (these benefits aggregate to a maximum of R190 000 per insured person per year)

Benefit for shortfalls in medical practitioner costs

This benefit addresses the shortfall that occurs between the fees charged by medical practitioners and the amount reimbursed by your medical scheme. Coverage extends up to three times the amount paid by the medical scheme. Furthermore, Momentum GapCover also provides coverage for specific medical procedures performed outside of a hospital environment, in day clinics, or other registered facilities, again up to three times the amount reimbursed by the medical scheme. The total coverage you can receive will depend on your selected option, as outlined below:

• Ingwe, Fusion, 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 financial shortfall between the fees charged by allied professionals and the amount reimbursed by the Momentum Medical Scheme for in-hospital care that follows an associated in-hospital procedure. Coverage is limited to three times the amount paid by the Momentum Medical Scheme towards in-hospital shortfalls and capped at R2,500 per policy per year. A detailed list of the allied professionals covered can be found on page 5.

Co-payments

This benefit covers any co-payments that your medical scheme applies to hospital admissions, procedures, and certain treatments performed in day clinics. However, it is important to note that this benefit does not extend to co-payments incurred due to the voluntary use of non-Designated Service Providers.

Co-payments on oncology treatment

Momentum GapCover will cover the 20% co-payment that is applied to oncology treatment once the medical scheme limit has been exceeded.

Robotic procedure shortfall benefit

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

Robotic procedure co-payment benefit

In the event that your medical scheme imposes a co-payment for robotic-assisted surgery, Momentum GapCover will cover you for up to R12,000 per policy per year.

Casualty benefit

This benefit covers casualty fees associated with emergency room admissions at registered hospital casualty facilities due to medical emergencies or accidents. The coverage is limited to five casualty visits and up to R23,000 per policy per calendar year. Notably, three of these casualty visits may be utilized exclusively in emergencies for dependents aged seven years or younger. The emergency benefit is capped at R4,000 and will count towards your total of five claim events and the R23,000 annual benefit limit.

Internal prosthesis shortfall benefit

This benefit covers shortfalls associated with internal prosthesis costs, up to a maximum of R35,000 per policy per year. Specific sub-limits apply, such as R8,000 per claim event for stents and pacemakers, although this is subject to the overall policy limit of R35,000.

Assist benefits (these benefits do not aggregate to the R190 000 cap)

Cancer Assist benefit

In the unfortunate event that you are diagnosed for the first time with a minimum stage 2, local and malignant cancer, we will provide you with a payment of R8,000. If you are diagnosed with minimum stage 2, regional and malignant cancer, the payout increases to R20,000. Additionally, if you receive the R20,000 benefit and your medical scheme pays over R200,000 for your oncology treatment within 12 months of your diagnosis, we will grant you a further R15,000. This benefit is available only 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 assistance cover of R15,000 per policy per year. This benefit can be utilized to cover costs incurred for the treatment or related expenses.

Accident Assist benefit

This benefit offers a payout of R55,000 in the event of death or permanent disability resulting from an accident. This benefit is subject to one claim per insured individual for their lifetime.

Violent crime benefit

In the event that you or a dependent successfully claims the Accident Assist benefit due to a violent crime, we will double the payout amount to R110,000.

Premium waiver benefit

If you or a dependent responsible for paying the monthly premium for 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 their monthly medical scheme contributions and gap cover premium with an upfront payment of R36,000.

Trauma and bereavement counselling benefit

If you have been a victim of or a witness to an act of violence—such as murder, assault, robbery, rape, kidnapping, or hijacking—or if you experience a traumatic accident or suffer the loss of an immediate family member, we will cover trauma counselling fees at a rate of R800 per session, limited to R30,000 per policy per year.

Baby bump benefit

If you become pregnant while covered under this policy, we will provide you with an upfront amount of R2,500 to help with any unexpected expenses that may arise.

Please be aware that you can only apply for Momentum GapCover if you are a member of the Momentum Medical Scheme.

Premiums

<30 (Millennial GapCover)

R236

<42

R379

> 42

R533

>65

R669

These rates are applicable per policy on a monthly basis. It is important to note that no dependents may be added to Momentum GapCover if the principal insured individual is over 65 years old or if they are enrolled in Millennial GapCover.

Quotes for employer groups

For groups consisting of more than 20 members who are not currently covered by another gap provider, premiums will be calculated based on the group's demographics. Factors such as the average age of the group, the total number of members, and whether membership is voluntary or compulsory will be considered. For groups exceeding 20 members that are covered by another gap provider, we will require a minimum of three years of loss ratio data or the average claim spending per member per month.

Waiting periods

For individuals or groups with fewer than 20 members:

• There is a 3-month general waiting period that applies to all claims.
• A 9-month waiting period is imposed on any pre-existing physical defects, injuries, diseases, illnesses, or medical conditions for which medical advice, diagnosis, care, or treatment was recommended or received within the last 12 months.
• A 12-month waiting period applies to cancer cases where the insured individual has received or been recommended for medical advice, diagnosis, care, or treatment for any type of cancer within the past 12 months. Additionally, this waiting period applies to cases of birth or pregnancy if the insured individual has given birth within the last 12 months or is currently pregnant.

For voluntary groups with over 20 members:

• The 3-month general waiting period does not apply.
• A 9-month waiting period applies to pre-existing conditions.
• A 12-month waiting period applies to cancer of any type, pregnancy, and birth.

For compulsory groups with over 20 members:

• All waiting periods will be waived.
• The 3-month general waiting period is not applicable.
• The 9-month waiting period for pre-existing conditions is not applicable.
• The 12-month waiting period is not applicable.

How to claim

Claims for Momentum GapCover shortfalls are processed in a seamless manner. Our system is designed to automatically identify any potential GapCover claims, eliminating the need for you to fill out a claim form or submit documentation. We will notify you of any potential gap cover claims and inform you of the outcome shortly thereafter. This seamless claims process applies to the following types of claims:

• Shortfall for medical practitioners for in-hospital procedures.
• Co-payments.
• Oncology co-payments.
• Internal prosthesis.
• Casualty benefit.
• Baby bump benefit.

If you are submitting a claim for any of the following Assist benefits, you will need to complete a claim form to provide us with additional information:

• Cancer Assist payout for a cancer diagnosis.
• Accidental death or disability claims.
• Violent crime claims.
• Premium waiver claims.
• Trauma and bereavement counselling claims.

We cover these out-of-hospital/day clinic procedures

The following is a comprehensive list of out-of-hospital/day clinic procedures that we will cover:

• Urology: Circumcision (when deemed medically necessary), cystoscopy, orchidopexy, prostate biopsy, and vasectomy.
• Ear, Nose, Throat: Adenoidectomy, direct laryngoscopy, grommets, myringotomy, sinus surgery, and tonsillectomy.
• Orthopaedic: Arthroscopy, bunionectomy, carpal tunnel release, and ganglion surgery.
• Radiology: CAT scans, MRI scans, PET scans, nuclear radiology, varicose vein removal, and x-rays.
• Gastro-intestinal: Closure of colostomy, colonoscopy, endoscopy, gastroscopy, laparoscopy, oesophagoscopy, and hemorrhoidectomy.
• Gynaecology: Cervical laser ablation, dilatation and curettage, hysteroscopy, and tubal ligation.
• Cardiovascular: Coronary angioplasty and angiogram.
• Ophthalmology: Cataract removal, pterygium removal, and trabeculectomy.
• General Surgery: Hernia repairs and specific biopsies.
• Obstetrics: Childbirth in a non-hospital setting.
• Oncology: Chemotherapy and radiotherapy.
• Renal: Kidney dialysis.

Allied professionals that we cover

We provide coverage for services rendered by the following allied professionals:

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

What we do not cover

Medical expense shortfall benefit

• Shortfalls where your medical scheme has not paid the initial portion of costs.
• Hospital and day clinic fees, including theatre charges, ward charges, or any other associated costs.
• Pre-admission or out-of-hospital consultation fees.
• Materials or medications utilized during a procedure.
• Dental implants.
• Appliances such as wheelchairs, crutches, braces, etc.
• Out-of-hospital dental procedures.
• Home and private nursing services.
• Procedures conducted for cosmetic reasons.
• Exploratory procedures such as blood tests, pap smears, ultrasounds, etc.
• Procedures that are covered by your medical scheme on an exception or ex-gratia basis.
• Procedures specifically aimed at treating obesity.
• Any costs directly incurred as a result of the patient's Body Mass Index (BMI) or body weight.
• Hospice or step-down facilities.
• Routine medical examinations such as annual check-ups, including pap smears.
• Mental health disorders including anxiety disorders, mood disorders, psychotic disorders, dementias, and eating disorders.
• Transportation costs incurred in emergency situations, including those involving emergency vehicles or aircraft, as well as emergency medical service charges.
• Auxiliary or para-medical services, such as those provided by speech therapists, audiologists, physiotherapists, etc.

Allied professionals

• Any shortfalls incurred for allied professionals that are not part of the same hospital admission and treatment.
• Any shortfalls for allied professionals not included on our list.

Co-payment benefit

• Co-payments incurred for using a non-Designated Service Provider (non-DSP).
• Co-payments resulting from not adhering to the medical scheme's protocols (e.g., failing to obtain a referral from a GP to a specialist, not securing pre-authorization for a procedure, etc.).
• Co-payments related to the use of a private ward or any other special requests that are not covered by your medical scheme.
• Co-payments associated with a condition for which you are in a waiting period.

Oncology co-payment benefit

• Co-payments incurred for receiving treatment from a non-Designated Service Provider.

Internal prosthesis shortfall benefit

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

Casualty benefit

• Elective procedures conducted in a casualty ward.
• Casualty ward visits due to illness for children older than seven years.

Robotic procedure shortfall benefit

• Any other shortfalls related to the procedure, excluding medical practitioner costs.

Robotic procedure co-payment benefit

• Any amounts exceeding the R12,000 annual limit.

Benefit for first-time cancer diagnosis

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

Benefit for accidental death or accidental permanent and total disablement

• 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 according to the policy.

Benefit for accidental death or accidental permanent and total disablement due to a violent crime

• Death or permanent and total disablement not directly caused by a violent crime as defined in the policy.
• Disability that is not classified as total and permanent according to the policy.

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

• 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 according to the policy.

Benefit for trauma or bereavement counselling

• Any counselling that is not related to an act of violence or a traumatic accident.
• Any counselling not provided by a counselor as defined in the policy.
• Counselling related to the death of a family member not specified in our policy wording.

Baby Bump benefit

• Any pregnancy that is not confirmed by the specific criteria outlined in the policy.

General exclusions

We do not cover any claims arising from the following events:

• Participation in war, invasion, terrorist activities, rebellion, active military duty, police duty, civil commotion, labor disturbances, riots, strikes, or activities of locked-out workers.
• Incidents involving nuclear weapons, nuclear materials, ionizing radiation, or contamination from nuclear waste, including any self-sustaining nuclear fission processes.
• Use of any legal drug unless prescribed by a registered medical practitioner and taken according to their instructions.
• Use of any illegal drug.
• Engaging in illegal activities or breaking any laws of the Republic of South Africa.
• Suicide, attempted suicide, intentional self-injury, or any exposure to danger.
• Aviation activities, except when on a commercial flight as a paying passenger.
• 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, other than on foot or involving non-mechanically propelled vehicles, vessels, crafts, or aircraft.

Terms and conditions of cover

All benefits provided are subject to the terms and conditions outlined in the policy. A detailed description of these terms, conditions, and exclusions is available upon request or can be found in the policy document.

This information is protected by applicable intellectual property laws and may not be copied, distributed, or modified for commercial purposes. While every effort has been made to ensure that the information provided is current, fair, and accurate, there is no guarantee of this. The use of this information by any third party is at their discretion and is intended for informational purposes only. The content 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 explicitly or implicitly endorse, recommend, or suggest that the products or services mentioned are suitable for any third party's specific needs. Furthermore, Guardrisk Insurance Company Limited disclaims any liability for any loss, damage, costs, or expenses that may arise directly or indirectly from any errors or omissions in this document.

+Members of the Momentum Medical Scheme have the option to utilize additional products offered by Momentum Group Limited (Momentum) to seamlessly enhance their medical aid coverage. It is important to understand that Momentum is not a medical scheme and operates as a separate entity from the Momentum Medical Scheme. The complementary products offered are not classified as medical scheme benefits. You can be a member of the Momentum Medical Scheme without taking any of the complementary products.