Vital Cover Plus

Applies to authorised in-hospital and in-lieu of hospital procedures, where the medical aid pays a portion of the fees from its in-hospital or major medical benefit. (Includes MRI/ CT/PET scans consumables.)

R1 050 per policy per annum.

Pain Relief Benefit – Provides cover for targeted pain relief treatment during surgery or following a severe trauma. This is covered even if the medical aid pays from day-today benefits or savings, provided the treatment forms part of an authorised in-hospital procedure, funded from the medical aid’s Risk or Major Medical Benefit: Unlimited but subject to the aggregate annual limit per insured person per annum.

Tariff Shortfall cover for service provider costs related to in-hospital mental health admissions requiring psychiatric care: 21 days.

Cover for the shortfall on a specialist account related to the consultation in the rooms before a member is going for an in-hospital procedure.

Limited to the following number of consults p.p.p.a (up to a max of R500 per consult).

2 consults per policy per annum.

Sometimes accidents occur and you need to rush to casualty.

Your medical aid does not always cover the total costs in full. Whether payment comes from your medical scheme savings account or day-to-day benefit, the gap will be covered, provided it is for an ACCIDENT, and the treatment provided is at a casualty unit linked to a hospital.

Sometimes the medical aid will not account for anything regarding this casualty visit, leaving you to cover the bill in full. This benefit will cover you for up to R9 240 per policy per annum (subject to the annual limit*) EVEN IF YOUR MEDICAL AID COVERS NOTHING.

Children under the age of 8 ONLY – May be admitted for any treatment at a casualty unit linked to a hospital between the hours of 7 pm to 7 am from Monday to Friday, from 7 pm on a Friday until 7 am on a Monday, and all day on a public holiday.

Casualty follow-up consultations

(The initial treatment must have taken place in a casualty/ER unit linked to a hospital following an accident.) 

1 follow-up consultation per policy per annum at an ER unit (accident-related only).

• These days most medical aid schemes impose a sub-limit on in-hospital internal prostheses costs. Members may be out of pocket and will have to cover these costs themselves.
  Prosthesis sub-limit: This benefit provides an amount of up to R5 775 per policy per annum, subject to the annual limit*.
• No other sub-limits are included in this benefit.

Accidents happen! Unfortunately, some severe accidents may even result in death. The situation is made worse if that person was the main breadwinner. Costs can run into the thousands and often funds are tied up to an estate.

• This benefit will provide an amount of R11 000 in the event of death of the insured and / or spouse, and
• R6 060 in the event of the death of the dependent, caused by violent, accidental, external, or visible means.

• Benefits: Home Drive, Uber, Panic Button (includes a Roadguard service), Medical Health Line & Trauma Counselling Line (including a COVID-19 care line) and Claims Submissions.
• Click here for more information.

• Dental Benefit: Up to an aggregate of R226 881 per insured person per annum. The shortfall that arises after your medical aid has processed your account and is due to service providers charging above scheme tariff for authorised dental procedures performed in hospital or in doctor’s rooms and paid from the in-hospital or major medical benefit only.
• The cover is limited to a percentage of the original scheme tariff, as follows:
  • Adults and dependants over 18 years of age: Treatment of impacted wisdom teeth, extractions, apicoectomies or loss of teeth due to oncology or trauma ONLY.
  • Dependants up to 18 years of age: Any procedure or treatment.

• These days most medical aid schemes insist that members pay an upfront amount for certain diagnostic and endoscopic procedures like gastroscopies and colonoscopies. This amount is known as a co-payment or deductible.
• This benefit will cover you for up to R14 335 per policy per annum (subject to the annual limit*) for co-payment or deductible costs imposed by your medical aid, provided you make use of your medical aid’s designated service provider network.
• NO cover is provided where a policyholder voluntarily chooses to make use of a service provider that is not part of their medical aid’s service provider network.

• Oncology Gap Benefit: Up to an aggregate of R226 881 per insured person per annum. The shortfall that arises after your medical aid has processed your account and is due to service providers charging above scheme tariff for medical aid approved oncology treatment plans. (NB: Subject to: the gap cover percentage; and medical aid approved treatment plan being covered up to scheme tariff and within annual scheme oncology limit).
• Oncology Co-Payment Benefit (In Network): Up to R14 333 per policy per annum

• The co-payment or deductible that your medical aid charges you for certain in-hospital procedures. This co-payment is NOT related to the scheme tariff and service provider charge shortfall or designated service provider none arrangements, OR
• For claims where the medical aid will only pay a percentage for the approved treatment and the policyholder needs to pay the remaining percentage of the account.
• All costs to be within the annual scheme oncology limit.

• We often hear of cases where one of our policyholders passes away, leaving their loved ones to pick up the pieces. They are left with the challenge to make sure that the gap cover they were used to is funded for a period of time.
• This benefit will provide for your gap cover premiums for a period of 12 months after the accidental death of the original policyholder

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. Up to a max. of R6 060 per month.

• All TRA Gap Cover policyholders, under the age of 71, have access to the benefit of comprehensive travel insurance which you can read about HERE.
• Benefits include but are not limited to:
  • Emergency Medical and Related expenses: R1 000 000
  • Medical Evacuation, Repatriation or Transportation to a Medical Centre: Actual expense covered when arranged by Hepstar Financial Services.
  • Personal Accident Cover: Death: R25 000 / Permanent Disability: up to R25 000
  • Theft or Accidental Damage during trip: R5 000 / Single item limit: R1 500
  • Theft, Damage or loss by Airline: R5 000 / Single item limit: R1 500
  • Baggage Delay (more that 4 hours): R500
  • Baggage Delay (more that 24 hours): R1 000
• In addition, you may purchase a top-up plan by clicking HERE to increase your medical and baggage related cover, as well as add cover for trip cancellation, pre-existing medical conditions, missed connections and more.

  If you are a TRA policyholder, and you need eSIM services, you also have access to a unique link which will take you the SIMTEX website – there, you will Click “Get your eSIM” to purchase your eSIM and data. Your 20% discount will be applied upon checkout! Easy as that. To get your unique link, refer to your year-end email communications from TRA, or contact membership@totalrisksa.co.za.

Vital Cover Plus is a mid-level Gap Cover policy from Total Risk Administrators. It helps cover certain medical aid shortfalls during hospital procedures and includes additional benefits such as co-payment cover, sub-limit protection and oncology gap benefits.

Vital Cover Plus includes cover for specialist tariff shortfalls, co-payments required by medical schemes, certain sub-limit shortfalls, casualty unit benefits and oncology gap cover. Eligible in-hospital shortfalls may be covered up to 700% of the medical scheme tariff, subject to policy terms.

The combined benefits under Vital Cover Plus are subject to an aggregate annual limit of R226 881 per insured person per year, in line with current regulatory limits.

Vital Cover Plus may suit individuals or families who want broader protection than entry-level Gap Cover. It provides additional financial protection against co-payments and certain sub-limits that may arise during hospital treatment.

While Basic Cover 300 focuses mainly on tariff shortfalls at 300% of the medical scheme tariff, Vital Cover Plus extends protection to 700% and includes co-payment cover and certain sub-limit protection. If your medical scheme requires co-payments for hospital admissions or you want broader cover against specialist fees, Vital Cover Plus may be the better fit.