AskAdam gap cover can pay for:

  • Service providers such as specialists, surgeons, anaesthetists who charge in excess of medical scheme rate for authorised in-hospital procedures and specified out-of-hospital procedures
  • Out-patient chemotherapy, radiotherapy and kidney dialysis
  • Co-payments required by the scheme, in-hospital
  • Co-payments for out-of-hospital MRI and CT scans
  • An increase of sub-limits
  • Additional cancer cover
  • ER costs

To get a detailed explanation of each of these benefits, see here.

AskAdam gap cover does not pay for:

  • Charges above medical scheme tariff for hospital costs and medication eg cost of bed, food, banadges, blood
  • Any procedure not covered or declined by the medical scheme
  • Any PMB (charges which should be provided for by medical scheme)
  • Split billing. (This occurs when doctor submits one bill to medical aid, and an additional bill to patient. This is illegal)
  • Shortfalls or penalties related to use of non-DSP or out-of-network provider
  • Day expenses
  • Extended family members
  • (This is not an exhaustive list, and you should consult the policy document for all details)

Gap Shortfall benefit

  • This pays for charges levied by the Medical Services Professionals above the Medical Scheme Tariff for associated services in-hospital and/or the necessity for chemotherapy or radiotherapy for the treatment of Cancer on an out-patient basis, and/or the necessity for kidney dialysis on an out-patient basis;
  • Limited to 5 times the Medical Scheme Tariff.
  • Does not provide for charges above the tariff for the hospital costs or for additional costs of prosthesis, materials and medication. Cover is for the services provided by Specialists, General Practitioners and Medical Professionals such as Physiotherapists during the period of hospitalisation.

Co-payment benefit

  • Pays for charges in the form of a co-payment or deductible applied for in-hospital admissions
  • Also pays co-payments or deductibles for specialised diagnostic radiology limited to MRI and CT Scans.
  • A Co-payment is a procedure-specific upfront payment charged by the Medical Aid Scheme, payable to the Medical Services Provider prior to undergoing the procedure.
  • Will not pay a benefit if the co-payment was due to a penalty such as the failure to apply for pre-authorisation or where the member did not use a network hospital. This include the co-payment or sub-limitation imposed by the medical scheme through agreement with the policyholder where the co-payments or sub-limitations are not indicated in the rules of the medical scheme such as the use of robotic equipment for certain surgical procedures.

Sub-limit benefit

  • Covers the charges above any sub-limitation imposed by the Medical Scheme for in-hospital admissions.
  • Sub-limits are limits set by the Medical Aid Scheme on medical aid benefits.

ER benefit

  • Covers you for treatment received in a casualty unit of a hospital provided that such treatment is not for routine physical treatment or any other medical examination or treatment other than emergency medical treatment.
  • You are covered when immediate treatment is required and your medical scheme does not provide you with cover and you become liable to pay the cost of the casualty event.
  • This benefit will cover the facility fee, consultations, medications, radiology and pathology associated with admission to a registered hospital’s casualty facility.
  • “Emergency” means the sudden and at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or death. The determination of an Emergency will be done through diagnosis (through classification by the attending Medical Practitioner and / or the Casualty Unit) and not on symptoms presented. The Medical Practitioner that treated you and / or the Casualty Unit that you have been treated in should use the correct codes and classification on the invoices they send to you and /or your medical aid.

Cancer cover benefit

  • This benefit kicks in only once you or the medical scheme have paid R200,000 in cancer treatment costs per year, in a private facility
  • The benefit will then pay most costs not paid by medical aid, including co-payments, up to the R150,000 overall limit per person per year
  • The benefit will also pay charges for defined biological cancer drugs, if the medical aid plan has these as a benefit
  • Treatment includes in-hospital expenses, chemicals, medication and outpatient radiotherapy or chemotherapy however treatment excludes the cost of specialist’s consultations.

Biological Cancer drugs benefit

  • Limited to: Herceptin, Mylotarg, Nexavar, Gleevec, Sprycel, Faslodex, Velcade, Tarceva, Alimta, Zevalin, Avastin, Erbitux, Sunitinib, Sutent, Fludara, Mabthera, Votrient, Gemzar, Cisplatin, Everolimus with specific oncological condition and/or specific sub-groups of cancers limited to subgroups of the following categories:
    • HER 2-positive Breast Cancer
    • Acute myeloid leukaemia
    • Advanced hepatocellular carcinoma
    • Acute lymphoblastic leukemia
    • Chronic myeloid leukemia
    • Chronic lymphocytic leukemia
    • Hairy cell leukaemia
    • Myelodysplasia
    • HER 2-negative breast cancer
    • Gastrointestinal stromal tumour
    • Multiple myeloma
    • Non small cell lung cancer
    • Non-hodgkins lymphoma
    • Metastatic colorectal cancer
    • Advanced renal cell carcinoma
    • Head and neck cancer

Other articles about AskAdam gap cover

For more information on the gap product, please read the articles below, or contact us with any questions.

The AskAdam gap products are not a medical scheme, and the cover is not the same as that of a medical scheme. The policy is not a substitute for medical scheme membership. The master policy issued is the source of all benefits, and obligations and exclusions.

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