Day Hospital/Clinic and/or In Room Surgical Procedures Cover
PMB Cover
Hospital Account Shortfalls
Sub-limit Enhancer
Step-down
Gap Cover
Gap Cover
Will settle claims at an additional 500% above Medical Scheme rate or at the
stated benefit value. In the event of a claim for robotic surgery appearing on the
hospital account only, we will cover up to a sub-limit of R30 000 per policy per
annum, limited to R12 000 per claim with a maximum of 2 claims per beneficiary
per policy per annum.
Co-payments
Co-payments
Are the excesses imposed by your medical scheme payable to a maximum rand limit for specified procedures or tests. Cover for co-payments imposed by medical schemes for hospital admissions, scans and surgical procedures. Co-payments related to cancer are catered for in a separate benefit category.
Co-payments Charged as a Percentage
Co-payments Charged as a Percentage
If your medical scheme defines your co-payment as a percentage of the benefit,
your co-payment benefit will be limited to a maximum payment of R16 000 per
claim.
Penalty Fee Cover
Penalty Fee Cover
Subject to a sub-limit of R10 500 per claim and a maximum of 3 claims per
policy per annum for the voluntary use of a non-designated service provider
(network hospital). This includes the use of a partial cover network hospital
a s determined by your medical scheme.
Day Hospital/Clinic and/or In Room Surgical Procedures Cover
Day Hospital/Clinic and/or In Room Surgical Procedures
Cover
Will settle the GAP portion of claims.
PMB Cover
PMB Cover
This benefit will cover the shortfall resulting from the use of a non-designated
service provider for planned procedures except in the event of an emergency.
Hospital Account Shortfalls
Hospital Account Shortfalls
Subject to a sub-limit of R5 000 per policy per annum. Maximum of R1 250 per
claim. Maximum 3 claims per beneficiary.
Sub-limit Enhancer
Sub-limit Enhancer
Sub-limit of R100 000 per policy per annum subject to R25 000 per claim.
Maximum of 2 claims per beneficiary limited to 4 claims per policy per annum.
The sub-limit enhancer benefits are limited to MRI scans, intraocular lenses, CT
scans and internal prosthesis only.
Step-down
Step-down
A sub-limit of up to R9 000 per policy applies to this section of cover. In the
event that your medical scheme provides benefits for rehabilitation as an
inpatient in a step-down or sub-acute facility, resulting from an accident, cover
will be provided for ongoing treatments by resident healthcare practitioners
during your recovery once medical scheme benefits have be exhausted or limits
have been reached.
Out-of-hospital Benefits
Primary Care Consultation Benefits
Emergency Room Cover
Day-to-day Specialist Consultation Fee
Preventative Care Cover
Appliance Benefit
Trauma Counselling
Primary Care Consultation Benefits
Primary Care Consultation Benefits
Subject to a sub-limit of R3 750 per policy per annum. A maximum of
3 consultations at R375 per claim. Applicable to GPs, dentists and
alternative therapists. This applies to the Gap portion only.
Emergency Room Cover
Emergency Room Cover
A sub-limit of R12 000 is applicable. This benefit covers an emergency at any
Registered Emergency Facility when you require immediate medical treatment
due to an accident or illness. The following benefits collectively accumulate to
the sub-limit. Accident benefit: all costs related to the accidental event will be
covered and paid to a maximum value of the sub-limit available, whether you
are liable to pay the costs related to the emergency event out of your own pocket or if your medical scheme pays from your savings account. Illness benefit:
when you visit an emergency room in a medical emergency as a result of
illness, we will cover the Gap portion only if the medical scheme has paid a
portion. Emergency illness benefit: This benefit is applicable to children under
the age of 8 who require out of normal consultation hours. All costs related to
the event will be covered and paid to a maximum value of the sub-limit
available, whether you are liable to pay the costs related to the emergency
event out of your own pocket or if your medical scheme pays from your
savings account.
Day-to-day Specialist Consultation Fee
Day-to-day Specialist Consultation Fee
Subject to a sub-limit of R6 500 per policy per annum. R1 350 per claim. 4
claims per beneficiary per annum for the Gap portion only.
Preventative Care Cover
Preventative Care Cover
R8 000 sub-limit per policy. R1 200 per claim. Maximum 3 claims per
beneficiary per annum. Defined as pap smears, cholesterol tests, blood glucose
tests, flu vaccinations, childhood immunisations, bone density scans, prostate
specific antigen tests, mammograms, and contraceptive implantation.
Appliance Benefit
Appliance Benefit
Maximum claim amount R6 600 per policy per annum for your Gap component
as per the defined list; hearing aids, wheelchairs, CPAP machine, humidifiers,
insulin pump, glucometer, nebuliser and the Mirena device.
Trauma Counselling
Trauma Counselling
A sub-limit of R5 000 per policy per annum with a registered medical
professional. You will be covered within the first 6 months after a traumatic
incident. Limited to a stated benefit of R750 per claim. This benefit covers you
for, but is not limited to; dread disease, hijacking and/or violent crimes. (At the
discretion of the insurer, on the provision of supporting documentation.)
Cancer Benefits
Cancer Co-payment Benefit
Cancer Benefit - Boost
Cancer Benefit - Breast Reconstruction
Cancer Benefit - PMB
Cancer Co-payment Benefit
Cancer Co-payment Benefit
This Cancer Co-payment Benefit is applied once your medical scheme cancer
benefit has been reached and a percentage co-payment is imposed. This
benefit incorporates co-payments, and co-payments related to biological
drugs. In order to access this benefit, you need to be on a registered treatment
plan with your medical scheme.
Cancer Benefit - Boost
Cancer Benefit – Boost
Is limited to R100 000 per beneficiary per annum. This benefit is restricted to
policyholders where their medical scheme option has a defined rand limit for
cancer treatment. The Cancer Boost benefit can only be claimed once your
rand limit on your medical scheme cancer benefit has been reached and you
require ongoing treatment. This benefit is dependent upon the Insured having
already been registered on the medical scheme’s cancer programme. The
Cancer Boost benefits are limited to those that were determined within the
approved medical scheme treatment plan which must be submitted to Sirago
upon application for this benefit..
Cancer Benefit - Breast Reconstruction
Cancer Benefit – Breast Reconstruction
In the event of the medical scheme approving reconstructive surgery on the
affected breast, we will cover the Gap portion up to 300% of the claim. In
addition to this, Sirago will make available up to R25 000 for the
reconstruction of the non-affected breast. This benefit is available within the
first 12 (twelve) months of the initial mastectomy. We require, subject to
Sirago protocols, which include, but are not limited to: medical scheme
preauthorisation and a motivation/letter from your treating provider.
Cancer Benefit - PMB
Cancer Benefit – PMB
Please note the above benefits are only available in the event that the
treatments do not form part of the legislative PMB framework.
Value Added Benefits
Gap Cover Premium Waiver
Medical Scheme Premium Waiver
Accidental Death
Cancer Cover (Initial Diagnosis)
Sira-Go’ Baby
Gap Cover Premium Waiver
Gap Cover Premium Waiver
In event of death or total permanent disability of the policyholder of the Sirago
policy. The Premium Waiver is directly linked to your policy premium per month as
indicated in your schedule of insurance. This benefit is not paid in cash, but held as
a credit against the policy for the applicable 12 month period. Should there be any
premium adjustments within the 12 month period, the credit balance available for
the rest of the waiver period, will be adjusted accordingly. This benefit cannot be
transferred, ceded or converted to cash.
Medical Scheme Premium Waiver
Medical Scheme Premium Waiver
Payable in event of death or total permanent disability of the principal policyholder
of the Sirago Gap Cover. In the event of dual medical scheme membership, this
benefit is only payable in event of death or total permanent disability of the
principal policyholder. Sirago will pay the medical scheme premium to the actual
amount of the contribution, but not higher than the sub-limit of R4 500 per month
for a 6 month period which, will be paid to the beneficiary for the upkeep of their
medical scheme contributions. In order to receive the benefit, the Gap Cover
policy and medical scheme membership must remain active during this period. A
certificate of membership from your medical scheme must be presented monthly
for authentication of current membership.
Accidental Death
Accidental Death
R15 000 principal, R10 000 adult dependent, R5 000 per child per policy
per life.
Cancer Cover (Initial Diagnosis)
Cancer Cover (Initial Diagnosis)
This benefit will pay you a lump sum of R22 500 upon the initial diagnosis
of malignant cancer per beneficiary per annum as defined. This excludes any
incidence of cancer/pre-cancer prior to inception of the policy.
Sira-Go’ Baby
Sira-Go’ Baby
A branded Sirago welcome gift will be posted to your physical address, or
delivered to your contracted broker, as per your application form upon
receipt of the instruction to add the new-born child. The instruction to add
the child to the policy must be submitted within 31 days of the birth of the
child. (Subject to availability. Please allow 6 weeks for delivery.)
Get a Gap Cover solution that's tailored for your unique requirements
Sirago Underwriting Managers (Pty) Ltd is an Authorised Financial Services Provider (FSP:4710). Underwriting Agency for GENRIC Insurance Company Limited (FSP:43638). GENRIC is an Authorised Financial Services Provider and Registered Short-term Insurer.
Contact
Midrand Business Park, Building 3, 563 Old Pretoria Main Road, Midrand, 1685
