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Gap Cover is an insurance policy that covers the gap between what your medical aid pays and what service providers charge for in-hospital expenses.
Healthcare in South Africa is expensive, and most medical aids only cover part of the healthcare providers’ actual rate.
Gap cover offers you extra protection, covering the shortfall of your medical aid.
However, Gap cover is not a medical aid and does not replace your medical aid.
Gap Cover is an insurance policy that covers the gap between what your medical aid pays and what service providers charge for in-hospital expenses.
Healthcare in South Africa is expensive, and most medical aids only cover part of the healthcare providers’ actual rate.
Gap cover offers you extra protection, covering the shortfall of your medical aid.
However, Gap cover is not a medical aid and does not replace your medical aid.
TRA Gap Cover offers four tailor-made products that fit your needs based on your medical aid plan.
We know gap cover can be the difference between falling into debt and recovering from in-hospital expenses.
We help in the only way we know how: making our claims process one of the fastest in South Africa.
STANDARD BENEFITS
Gap Cover
Casualty Cover
Oncology Gap
Policy Extender
Accidental Death Cover
TRA Assist Powered by MobiMed
From R99/m
STANDARD BENEFITS
Gap Cover
Casualty Cover
Oncology Gap
Policy Extender
Accidental Death Cover
TRA Assist Powered by MobiMed
From R99/m
Basic Cover 300 | Vital Cover Plus | Super Cover Plus | Absolute Cover Plus | |
---|---|---|---|---|
Gap Cover Annual Limit R198 660 in aggregate per insured person per annum* (p/a) |
||||
Gap Cover Percentage* | 300% | 700% | 700% | 700% |
PMB's* Covered, subject to medical aid review |
||||
CO-PAYMENTS / DEDUCTIBLES* DSP’s (Voluntary use of designated service provider networks) |
Up to R13 000* per |
Up to R60 000* per |
Unlimited* |
|
CO-PAYMENTS / DEDUCTIBLES* NON DSP’s (Voluntary use of non-designated service provider networks) |
1 co-payment |
2 Co-payments / |
||
CO-PAYMENT BENEFIT*: OUT OF HOSPITAL/MRI/CT/PET SCANS |
1 MRI / CT / PET |
2 scans per |
||
SUB-LIMITS*: INTERNAL PROSTHESES |
Up to R5 500* per |
Up to R11 000* per |
Unlimited |
|
SUB-LIMITS*: MRI / CT / PET SCAN |
1 |
2 |
||
SUB-LIMITS*: COLONOSCOPIES AND GASTROSCOPIES |
Up to R13 000* per
Up to R3 600* per |
Up to R22 000* per
Up to R6 000* per |
||
DENTAL BENEFIT* Unlimited but subject to the aggregate annual limit per insured person p/a |
||||
CASUALTY UNIT BENEFIT* |
Up to R3 300* per |
Up to R8 800* per |
Up to R13 000* per |
Up to R22 000* per |
GLOBAL FEE BENEFIT* |
Up to R12 000* per |
Up to R24 000* per |
||
ONCOLOGY GAP BENEFIT* (Subject to medical aid approved treatment plan being covered up to scheme tariff and within annual scheme oncology limit) |
Up to an |
Up to an |
Up to an |
Up to an |
ONCOLOGY CO-PAYMENT BENEFIT (IN NETWORK)* |
Up to R13 000* per |
Up to R60 000* per |
Unlimited* |
|
ONCOLOGY CO-PAYMENT BENEFIT* (OUT OF NETWORK) |
1 co-payment per |
2 Co-payments per |
||
ONCOLOGY EXTENDER BENEFIT* (Includes ANY costs above annual scheme oncology limit but subject to scheme covering up to this limit) |
Up to R35 000* per |
Unlimited* |
||
ONCOLOGY “NEW-TECH” BENEFIT* |
Up to R8 200* per |
Up to R16 500* per |
||
ONCOLOGY GAP BENEFIT: BREAST RECONSTRUCTION SURGERY* |
Up to R18 000* per |
Up to R35 000* per |
||
MEDICAL AID CONTRIBUTION WAIVER
Provides cover towards a policyholder's medical aid contribution in the case of the accidental death of the main policyholder. Cover is limited to the lower of the actual medical aid contribution or the maximum amount allowed. |
6 months. |
6 months. |
6 months. |
|
MATERNITY PRIVATE WARD BENEFIT* |
Limited to a |
Limited to a |
||
ACCIDENTAL DEATH Insured / Spouse |
R7 000 |
R10 000 |
R20 000 |
R30 000 |
ACCIDENTAL DEATH Dependant |
R4 000 |
R5 500 |
R8 000 |
R20 000 |
POLICY EXTENDER (Additional 12 month gap cover premiums covered upon accidental death of policyholder) |
||||
TRAVEL BENEFIT Benefits include but are not limited to: |
||||
Emergency Medical and Related expenses : R600 000. Excess R500 |
||||
COVID-19 Extension: Emergency inpatient or outpatient treatment due to COVID-19 R600 000. |
||||
Medical evacuation, repatriation or transportation to a medical centre - FULL COST covered when arranged by Hepstar. |
||||
Hospital Cash benefit R500 per day (max R3 000). |
||||
Inconvenience Cover: Baggage Cover: R5 000 for theft, damage or loss by travel supplier. |
||||
TRA ASSIST POWERED BY MobiMed Home Drive (including Uber), Panic Button, Medical Health Line, Trauma Counselling Line (includes a COVID-19 CARE LINE) and Claims Submissions. |
ALL BASIC COVER BENEFITS PLUS
In Network Co-Payment Cover
Sub-Limit Cover
From R300/m
ALL BASIC COVER BENEFITS PLUS
In Network Co-Payment Cover
Sub-Limit Cover
From R300/m
Basic Cover 300 | Vital Cover Plus | Super Cover Plus | Absolute Cover Plus | |
---|---|---|---|---|
Gap Cover Annual Limit R198 660 in aggregate per insured person per annum* (p/a) |
||||
Gap Cover Percentage* | 300% | 700% | 700% | 700% |
PMB's* Covered, subject to medical aid review |
||||
CO-PAYMENTS / DEDUCTIBLES* DSP’s (Voluntary use of designated service provider networks) |
Up to R13 000* per |
Up to R60 000* per |
Unlimited* |
|
CO-PAYMENTS / DEDUCTIBLES* NON DSP’s (Voluntary use of non-designated service provider networks) |
1 co-payment |
2 Co-payments / |
||
CO-PAYMENT BENEFIT*: OUT OF HOSPITAL/MRI/CT/PET SCANS |
1 MRI / CT / PET |
2 scans per |
||
SUB-LIMITS*: INTERNAL PROSTHESES |
Up to R5 500* per |
Up to R11 000* per |
Unlimited |
|
SUB-LIMITS*: MRI / CT / PET SCAN |
1 |
2 |
||
SUB-LIMITS*: COLONOSCOPIES AND GASTROSCOPIES |
Up to R13 000* per
Up to R3 600* per |
Up to R22 000* per
Up to R6 000* per |
||
DENTAL BENEFIT* Unlimited but subject to the aggregate annual limit per insured person p/a |
||||
CASUALTY UNIT BENEFIT* |
Up to R3 300* per |
Up to R8 800* per |
Up to R13 000* per |
Up to R22 000* per |
GLOBAL FEE BENEFIT* |
Up to R12 000* per |
Up to R24 000* per |
||
ONCOLOGY GAP BENEFIT* (Subject to medical aid approved treatment plan being covered up to scheme tariff and within annual scheme oncology limit) |
Up to an |
Up to an |
Up to an |
Up to an |
ONCOLOGY CO-PAYMENT BENEFIT (IN NETWORK)* |
Up to R13 000* per |
Up to R60 000* per |
Unlimited* |
|
ONCOLOGY CO-PAYMENT BENEFIT* (OUT OF NETWORK) |
1 co-payment per |
2 Co-payments per |
||
ONCOLOGY EXTENDER BENEFIT* (Includes ANY costs above annual scheme oncology limit but subject to scheme covering up to this limit) |
Up to R35 000* per |
Unlimited* |
||
ONCOLOGY “NEW-TECH” BENEFIT* |
Up to R8 200* per |
Up to R16 500* per |
||
ONCOLOGY GAP BENEFIT: BREAST RECONSTRUCTION SURGERY* |
Up to R18 000* per |
Up to R35 000* per |
||
MEDICAL AID CONTRIBUTION WAIVER
Provides cover towards a policyholder's medical aid contribution in the case of the accidental death of the main policyholder. Cover is limited to the lower of the actual medical aid contribution or the maximum amount allowed. |
6 months. |
6 months. |
6 months. |
|
MATERNITY PRIVATE WARD BENEFIT* |
Limited to a |
Limited to a |
||
ACCIDENTAL DEATH Insured / Spouse |
R7 000 |
R10 000 |
R20 000 |
R30 000 |
ACCIDENTAL DEATH Dependant |
R4 000 |
R5 500 |
R8 000 |
R20 000 |
POLICY EXTENDER (Additional 12 month gap cover premiums covered upon accidental death of policyholder) |
||||
TRAVEL BENEFIT Benefits include but are not limited to: |
||||
Emergency Medical and Related expenses : R600 000. Excess R500 |
||||
COVID-19 Extension: Emergency inpatient or outpatient treatment due to COVID-19 R600 000. |
||||
Medical evacuation, repatriation or transportation to a medical centre - FULL COST covered when arranged by Hepstar. |
||||
Hospital Cash benefit R500 per day (max R3 000). |
||||
Inconvenience Cover: Baggage Cover: R5 000 for theft, damage or loss by travel supplier. |
||||
TRA ASSIST POWERED BY MobiMed Home Drive (including Uber), Panic Button, Medical Health Line, Trauma Counselling Line (includes a COVID-19 CARE LINE) and Claims Submissions. |
ALL VITAL COVER BENEFITS PLUS
Global Fee Benefit
Breast Reconstruction Surgery Benefit
Co-Payment: Out Of Hospital MRI/CT/PET Scans
Out of Network Co-Payment Cover
Oncology “New Tech” Benefit
Maternity Private Ward Benefit
From R330/m
ALL VITAL COVER BENEFITS PLUS
Global Fee Benefit
Breast Reconstruction Surgery Benefit
Co-Payment: Out Of Hospital MRI/CT/PET Scans (2023)
Out of Network Co-Payment Cover
Oncology “New Tech” Benefit
Maternity Private Ward Benefit
From R330/m
Basic Cover 300 | Vital Cover Plus | Super Cover Plus | Absolute Cover Plus | |
---|---|---|---|---|
Gap Cover Annual Limit R198 660 in aggregate per insured person per annum* (p/a) |
||||
Gap Cover Percentage* | 300% | 700% | 700% | 700% |
PMB's* Covered, subject to medical aid review |
||||
CO-PAYMENTS / DEDUCTIBLES* DSP’s (Voluntary use of designated service provider networks) |
Up to R13 000* per |
Up to R60 000* per |
Unlimited* |
|
CO-PAYMENTS / DEDUCTIBLES* NON DSP’s (Voluntary use of non-designated service provider networks) |
1 co-payment |
2 Co-payments / |
||
CO-PAYMENT BENEFIT*: OUT OF HOSPITAL/MRI/CT/PET SCANS |
1 MRI / CT / PET |
2 scans per |
||
SUB-LIMITS*: INTERNAL PROSTHESES |
Up to R5 500* per |
Up to R11 000* per |
Unlimited |
|
SUB-LIMITS*: MRI / CT / PET SCAN |
1 |
2 |
||
SUB-LIMITS*: COLONOSCOPIES AND GASTROSCOPIES |
Up to R13 000* per
Up to R3 600* per |
Up to R22 000* per
Up to R6 000* per |
||
DENTAL BENEFIT* Unlimited but subject to the aggregate annual limit per insured person p/a |
||||
CASUALTY UNIT BENEFIT* |
Up to R3 300* per |
Up to R8 800* per |
Up to R13 000* per |
Up to R22 000* per |
GLOBAL FEE BENEFIT* |
Up to R12 000* per |
Up to R24 000* per |
||
ONCOLOGY GAP BENEFIT* (Subject to medical aid approved treatment plan being covered up to scheme tariff and within annual scheme oncology limit) |
Up to an |
Up to an |
Up to an |
Up to an |
ONCOLOGY CO-PAYMENT BENEFIT (IN NETWORK)* |
Up to R13 000* per |
Up to R60 000* per |
Unlimited* |
|
ONCOLOGY CO-PAYMENT BENEFIT* (OUT OF NETWORK) |
1 co-payment per |
2 Co-payments per |
||
ONCOLOGY EXTENDER BENEFIT* (Includes ANY costs above annual scheme oncology limit but subject to scheme covering up to this limit) |
Up to R35 000* per |
Unlimited* |
||
ONCOLOGY “NEW-TECH” BENEFIT* |
Up to R8 200* per |
Up to R16 500* per |
||
ONCOLOGY GAP BENEFIT: BREAST RECONSTRUCTION SURGERY* |
Up to R18 000* per |
Up to R35 000* per |
||
MEDICAL AID CONTRIBUTION WAIVER
Provides cover towards a policyholder's medical aid contribution in the case of the accidental death of the main policyholder. Cover is limited to the lower of the actual medical aid contribution or the maximum amount allowed. |
6 months. |
6 months. |
6 months. |
|
MATERNITY PRIVATE WARD BENEFIT* |
Limited to a |
Limited to a |
||
ACCIDENTAL DEATH Insured / Spouse |
R7 000 |
R10 000 |
R20 000 |
R30 000 |
ACCIDENTAL DEATH Dependant |
R4 000 |
R5 500 |
R8 000 |
R20 000 |
POLICY EXTENDER (Additional 12 month gap cover premiums covered upon accidental death of policyholder) |
||||
TRAVEL BENEFIT Benefits include but are not limited to: |
||||
Emergency Medical and Related expenses : R600 000. Excess R500 |
||||
COVID-19 Extension: Emergency inpatient or outpatient treatment due to COVID-19 R600 000. |
||||
Medical evacuation, repatriation or transportation to a medical centre - FULL COST covered when arranged by Hepstar. |
||||
Hospital Cash benefit R500 per day (max R3 000). |
||||
Inconvenience Cover: Baggage Cover: R5 000 for theft, damage or loss by travel supplier. |
||||
TRA ASSIST POWERED BY MobiMed Home Drive (including Uber), Panic Button, Medical Health Line, Trauma Counselling Line (includes a COVID-19 CARE LINE) and Claims Submissions. |
ALL SUPER COVER BENEFITS WITH
HIGHER LIMIT AMOUNTS.
Maternity Private Ward Benefit
Oncology Extender Benefits
From R590/m
ALL SUPER COVER BENEFITS WITH
HIGHER LIMIT AMOUNTS.
Maternity Private Ward Benefit
Oncology Extender Benefits
From R590/m
Basic Cover 300 | Vital Cover Plus | Super Cover Plus | Absolute Cover Plus | |
---|---|---|---|---|
Gap Cover Annual Limit R198 660 in aggregate per insured person per annum* (p/a) |
||||
Gap Cover Percentage* | 300% | 700% | 700% | 700% |
PMB's* Covered, subject to medical aid review |
||||
CO-PAYMENTS / DEDUCTIBLES* DSP’s (Voluntary use of designated service provider networks) |
Up to R13 000* per |
Up to R60 000* per |
Unlimited* |
|
CO-PAYMENTS / DEDUCTIBLES* NON DSP’s (Voluntary use of non-designated service provider networks) |
1 co-payment |
2 Co-payments / |
||
CO-PAYMENT BENEFIT*: OUT OF HOSPITAL/MRI/CT/PET SCANS |
1 MRI / CT / PET |
2 scans per |
||
SUB-LIMITS*: INTERNAL PROSTHESES |
Up to R5 500* per |
Up to R11 000* per |
Unlimited |
|
SUB-LIMITS*: MRI / CT / PET SCAN |
1 |
2 |
||
SUB-LIMITS*: COLONOSCOPIES AND GASTROSCOPIES |
Up to R13 000* per
Up to R3 600* per |
Up to R22 000* per
Up to R6 000* per |
||
DENTAL BENEFIT* Unlimited but subject to the aggregate annual limit per insured person p/a |
||||
CASUALTY UNIT BENEFIT* |
Up to R3 300* per |
Up to R8 800* per |
Up to R13 000* per |
Up to R22 000* per |
GLOBAL FEE BENEFIT* |
Up to R12 000* per |
Up to R24 000* per |
||
ONCOLOGY GAP BENEFIT* (Subject to medical aid approved treatment plan being covered up to scheme tariff and within annual scheme oncology limit) |
Up to an |
Up to an |
Up to an |
Up to an |
ONCOLOGY CO-PAYMENT BENEFIT (IN NETWORK)* |
Up to R13 000* per |
Up to R60 000* per |
Unlimited* |
|
ONCOLOGY CO-PAYMENT BENEFIT* (OUT OF NETWORK) |
1 co-payment per |
2 Co-payments per |
||
ONCOLOGY EXTENDER BENEFIT* (Includes ANY costs above annual scheme oncology limit but subject to scheme covering up to this limit) |
Up to R35 000* per |
Unlimited* |
||
ONCOLOGY “NEW-TECH” BENEFIT* |
Up to R8 200* per |
Up to R16 500* per |
||
ONCOLOGY GAP BENEFIT: BREAST RECONSTRUCTION SURGERY* |
Up to R18 000* per |
Up to R35 000* per |
||
MEDICAL AID CONTRIBUTION WAIVER
Provides cover towards a policyholder's medical aid contribution in the case of the accidental death of the main policyholder. Cover is limited to the lower of the actual medical aid contribution or the maximum amount allowed. |
6 months. |
6 months. |
6 months. |
|
MATERNITY PRIVATE WARD BENEFIT* |
Limited to a |
Limited to a |
||
ACCIDENTAL DEATH Insured / Spouse |
R7 000 |
R10 000 |
R20 000 |
R30 000 |
ACCIDENTAL DEATH Dependant |
R4 000 |
R5 500 |
R8 000 |
R20 000 |
POLICY EXTENDER (Additional 12 month gap cover premiums covered upon accidental death of policyholder) |
||||
TRAVEL BENEFIT Benefits include but are not limited to: |
||||
Emergency Medical and Related expenses : R600 000. Excess R500 |
||||
COVID-19 Extension: Emergency inpatient or outpatient treatment due to COVID-19 R600 000. |
||||
Medical evacuation, repatriation or transportation to a medical centre - FULL COST covered when arranged by Hepstar. |
||||
Hospital Cash benefit R500 per day (max R3 000). |
||||
Inconvenience Cover: Baggage Cover: R5 000 for theft, damage or loss by travel supplier. |
||||
TRA ASSIST POWERED BY MobiMed Home Drive (including Uber), Panic Button, Medical Health Line, Trauma Counselling Line (includes a COVID-19 CARE LINE) and Claims Submissions. |
*SUBJECT TO AN AGGREGATE ANNUAL LIMIT OF R198 660 PER INSURED PERSON
This limit may be subject to regulatory amendment. Sub-Limits may apply. Refer to the Policy Document for full details of limitations and exclusions.
Terms and Conditions apply. This matrix does not constitute advice. Consult your intermediary for guidance in choosing the product that is right for your needs. Prescribed Minimum Benefits (PMB’s) are covered. Errors and Omissions Excepted. A full list of 2024 terms and conditions can be viewed here.
WE COVER THE GAP BETWEEN WHAT YOUR DOCTOR CHARGES
AND WHAT YOUR MEDICAL AID PAYS.
WE COVER THE GAP BETWEEN WHAT YOUR DOCTOR CHARGES AND WHAT YOUR MEDICAL AID PAYS.
Gap Cover eliminates financial stress in case of hospitalisation by protecting you from medical shortfalls. Never assume that your medical aid will cover 100% of your in-hospital expenses.
Gap Cover covers the gap between your hospital expenses and your medical aid shortfalls.
Gap Cover eliminates financial stress in case of hospitalisation by protecting you from medical shortfalls. Never assume that your medical aid will cover 100% of your in-hospital expenses.
Gap Cover covers the gap between your hospital expenses and your medical aid shortfalls.
Gap Cover is an affordable health insurance policy that gives you and your family peace of mind when you need it most.
Gap Cover is becoming a necessity in South Africa as doctors and medical aids continue to increase their rates exponentially each year.
Gap Cover is not a medical aid plan but has helped hundreds of South Africans avoid financial debt. You can visit our
Hello Peter page to find out how our policyholders feel about our service and Gap Cover products.
Gap Cover is an affordable health insurance policy that gives you and your family peace of mind when you need it most.
Gap Cover is becoming a necessity in South Africa as doctors and medical aids continue to increase their rates exponentially each year.
Gap Cover is not a medical aid plan but has helped hundreds of South Africans avoid financial debt. You can visit our
Hello Peter page to find out how our policyholders feel about our service and Gap Cover products.
Gap Cover is an affordable health insurance policy that gives you and your family peace of mind when you need it most.
Gap Cover is becoming a necessity in South Africa as doctors and medical aids continue to increase their rates exponentially each year.
Gap Cover is not a medical aid plan but has helped hundreds of South Africans avoid financial debt. You can visit our
Hello Peter page to find out how our policyholders feel about our service and Gap Cover products.
Gap Cover is an affordable health insurance policy that gives you and your family peace of mind when you need it most.
Gap Cover is becoming a necessity in South Africa as doctors and medical aids continue to increase their rates exponentially each year.
Gap Cover is not a medical aid plan but has helped hundreds of South Africans avoid financial debt. You can visit our
Hello Peter page to find out how our policyholders feel about our service and Gap Cover products.
Gap Cover is an insurance policy that covers the difference between what your medical aid pays and what service providers charge for in-hospital expenses.
Claims – Manual and Automatic Processes
The policyholder is responsible for ensuring that claims are submitted and received by TRA within six (6) months from the treatment date. The policyholder should also ensure that TRA has the correct banking details into which we must pay the claim.
Claims – Manual Process
Policyholders need to submit the following:
Claims – Automatic Process
TRA receives claims submitted by selected medical aid schemes on behalf of the policyholder. Should your medical aid company have such an agreement with TRA, it is optional for the policyholder to submit their claim to TRA.
TRA will receive an electronic version of the claim and will process the said claim within seven working days of receipt thereof.
Co-payment and sub-limit claims must always be submitted manually by the policyholder (in addition to all the required claims documentation, please also provide proof of any direct payment/s made to these service providers).
Should a claim be rejected because additional information (e.g. pre-authorisation letter, medical aid statement, doctor’s account or the first two pages of the hospital account) is not received, all the information must be submitted to TRA within 31 days from the date of the request or the claim will be rejected as late/stale in terms of this policy and will not be paid.
Most people purchase medical aid and assume they will take care of all their medical bills. Unfortunately, this is not always true. Medical shortfalls can occur if you need medical care for any reason – accident or illness. You don’t want to add financial worry to the stress of being hospitalised, which is why you need Gap Cover.
Gap Cover ensures you don’t receive a massive bill if there’s a shortfall between what the doctors charge and what your medical aid will pay for in-hospital procedures.
Discrediting common Gap Cover misconceptions with Total Risk Administrators, revealing its crucial role in complementing medical aid.
Gap cover has become an essential safeguard against unforeseen medical expenses for South Africans. With so many options available, understanding
Total Risk Administrators (TRA) is committed to offering comprehensive gap cover for various out-of-hospital procedures. The following article expands on
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Business Estate East
Copyright © 2023. | Terms and Conditions Apply. | Errors and Omissions Excepted.
Copyright © 2023. | Terms and Conditions Apply. | Errors and Omissions Excepted.