Gap Cover - Zestlife

Zestlife Universal Gap CoverZestlife Essential Gap CoverInternal Prosthesis and Artificial Joint CoverInternal Prosthesis and Artificial Joint CoverCover for up to R37 000 per policy per calendar year isprovided for medical expense shortfalls and co-paymentson the cost of internal prothesis. This cover is providedafter the exhaustion of the medical aid annual thresholdif the limit has been exceeded. No cover is providedunder this benefit for intraocular lenses, breast implants orprosthesis that are not permanently replacing a body partsuch as cardiac stents and orthopaedic rivets, anchorsand screws.Not applicable.In-hospital Dentistry Expense Shortfall CoverIn-hospital Dentistry Expense Shortfall CoverDentistry shortfalls are covered on doctor, dentist andspecialist charges of up to 500% of the medical schemetariff (MST). The shortfall cover amount provided iscalculated as: doctors and specialists charges (limitedto 5 times MST) less the greater of either the medicalscheme’s contribution to these costs or the MST.Not applicable.Robotic Medical Procedure CoverRobotic Medical Procedure CoverCover of up to R31 500 per policy per calendar year formedical expense shortfalls that arise directly from theuse of robotic machinery in the course of in-hospitaloperative treatment.Cover of up to R31 500 per policy per calendar year formedical expense shortfalls that arise directly from theuse of robotic machinery in the course of in-hospitaloperative treatment.SECTION B - HEALTH INSURANCE BENEFITSEnhanced Cancer Cover: Lump Sum Pay-outEnhanced Cancer Cover: Lump Sum Pay-outLump sum cover of R30 000 in the event of first timediagnosis with cancer, stage 2 and above. This benefitalso applies to stage 1 prostate cancer where theGleason score is 8 or higher. Payment of this benefit issubject to registration on the medical aid’s oncologytreatment program. This is a fixed benefit payment that isnot reliant on verification of actual treatment costs. Thiscover excludes skin cancer and only applies to the firsttime diagnosis of cancer after the commencement ofcover and after completion of the 12-month waiting period.Not applicable.Accidental Dentistry CoverAccidental Dentistry CoverR20 200 accidental tooth fracture cover due to anexternal blow to the mouth is provided per individual peryear. This cover is payable at a rate of R2 900 for eachtooth, irrespective of cover provided by the medical aid.R20 200 accidental tooth fracture cover due to anexternal blow to the mouth is provided per individual peryear. This cover is payable at a rate of R2 900 for eachtooth, irrespective of cover provided by the medical aid.Accidental Death and Permanent Disability CoverAccidental Death and Permanent Disability CoverA R50 000 lump sum benefit is paid in the event ofaccidental death or accidental permanent disability.The accidental permanent disability cover ceases atage 65.A R50 000 lump sum benefit is paid in the event ofaccidental death or accidental permanent disability.The accidental permanent disability cover ceases atage 65.Trauma Counselling CoverTrauma Counselling CoverCover of R750 per session for counselling is providedfollowing any individual insured under the policy beingsubject to or a witness to an act of violence or traumaticaccident. Counselling must commence within 6 monthsof the traumatic event and will be covered to amaximum of R25 000 over a single 6 month period.Cover of R750 per session for counselling is providedfollowing any individual insured under the policy beingsubject to or a witness to an act of violence or traumaticaccident. Counselling must commence within 6 monthsof the traumatic event and will be covered to amaximum of R25 000 over a single 6 month period.Medical Aid and Gap Policy – Premium WaiverCoverMedical Aid and Gap Policy – Premium WaiverCoverA lump sum benefit is payable equal to 12 times thepolicyholder’s combined gap cover and medical aidpremiums at the time of claim. This benefit is subject toa policy limit of R105 000 and is payable following theaccidental death or accidental permanent disability ofthe policyholder. Cover for this benefit ceases at age 65.Not applicable.3

MONTHLY PREMIUMSZESTLIFE UNIVERSAL GAP COVERZESTLIFE ESSENTIAL GAP COVERCOVER FOR INDIVIDUALSCOVER FOR INDIVIDUALSYounger than 55 years oldR426 pmYounger than 55 years oldR317 pm55-64 Years oldR539 pm55-64 Years oldR398 pm65 Years and olderR619 pm65 Years and olderR454 pmCOVER FOR FAMILIESCOVER FOR FAMILIESWhere all lives insured are youngerthan 65.R539 pmWhere all lives insured are youngerthan 65.R398 pmWhere one or more lives insured areolder than 65.R619 pmWhere one or more lives insuredare older than 65.R454 pm*An over-65 premium applies if the main medical scheme member or any of their dependants are 65 years orolder at commencement of their cover. Premiums are valid for 2021 and is subject to change on 1 Jan 2022.Please note: Gap Cover policy premiums are not tax deductible in the same way that your medical aidcontributions are. No IT3 tax certificates can therefore be issued for this purpose.Summaryof policyterms andconditionsThe policy terms and conditions of the Universal and Essential GapCover options are contained in the summary below. For the fullterms and conditions please refer to the policy document.PRE-EXISTING CONDITION EXCLUSIONUnique Policy Benefit: There are no general waiting periods orcondition specific waiting periods that withhold cover after thecommencement date of the policy.However no benefits are payable for a period of 12 months from thestart date of cover in respect of medical conditions, for which in the12 months before the start date of the cover, medical advice,diagnosis, care or treatment was received or would reasonablyhave been recommended.Pregnancy before the start date of cover will be regarded as a preexisting condition and any pregnancy and birth related claims will beexcluded for 12 months from the start date of the cover.If prior to the start date of cover a policyholder had cover underanother Medical Expense Shortfall Policy with similar benefits, thenthe pre-existing condition waiting period will only be applied to theunexpired part of the pre-existing condition period from the previouspolicy. The pre-existing condition exclusion will however apply for thefull period of 12 months for any benefit not provided under the previousMedical Expense Shortfall Policy.4

GENERAL EXCLUSIONSNo benefits will be paid for claims arising from:Summaryof policyterms andconditions(Continued) Nuclear weapons or nuclear orionizing radiation. Suicide, attempted suicide orintentional self-injury. The taking of any drug or narcoticunless prescribed by and taken inaccordance with the instructions of aregistered medical practitioner (otherthan the insured person). Illness or injury caused by the use ofalcohol. Illegal behaviour, or as a result ofbreaking the law of the Republic ofSouth Africa. Participation in war, terrorist activity,invasion, rebellion, active militaryduty, police duty, police reservistduty, civil commotion, labourdisturbances, riot, strike or theactivities of locked out workers. Aviation accident, except on acommercial flight as a fare-payingpassenger. Participation in any form ofrace or speed test involving anymechanically propelled vehicle,vessel, craft or aircraft.SPECIFIC EXCLUSIONSNo benefits are payable for: Cosmetic surgery unless required dueto illness or injury. Penalty co-payments imposed bymedical aids for not following therules of the medical aid. Examplesof these penalties are amounts dueas a result of not obtaining a preauthorisation from the medical aid fora procedure, or consulting a specialistwithout first obtaining a referral from ageneral practitioner, or not going foran assessment through your medicalscheme’s programme as required(prior to undergoing surgery) suchas your scheme’s back and neckprogramme before having spinalsurgery. Pre- and post-hospitalisation doctorsand specialists charges. Treatment for obesity or treatment thatis required as a result of obesity. Elective or routine procedures andphysical examinations includingtests, annual check-ups, ECGs andcontraception-related treatments. Treatment for depression, mental orstress-related conditions. Claims not covered by the medical aid. Private and home nursing.Hospital charges.Medication and other materials.External prosthesis.Cancer treatment or plannedprocedures received outside theRepublic of South Africa.When travelling abroad, treatmentfor accident and illness is not coveredafter 60 consecutive days outside theRepublic of South Africa.Day-to-day medical practitionercharges.Breast or dental implants.Emergency medical transportation.Out-of-hospital dental procedures.Exploratory procedures or proceduresthat are paid for by your medical aidon exception or ex-gratia basis.Diagnosis and/or treatment forsleeping disorders.Treatment costs for services renderedby allied health care professionals,such as but not limited to dieticians,podiatrists, audiologists, chiropractors,acupuncturists, speech therapists,biokineticists, occupational therapists,scientists and technologists.CLAIMSAll claims must be lodged within 180 days of the medical treatment giving rise to theclaim. The claim form can be found on www.zestlife.co.za.Claim pay-outs are either made to the policyholder or directly to the treatingdoctors, specialists or medical service providers, at the insurer’s discretion.5

Extended cover optionsExtendedLump SumCancerCoverThis is an optional policy benefit that will pay-out either R100 000 or R200 000in the event of the first-time diagnosis of cancer. This covers the policyholderand medical aid dependants insured under the policy. This cover can betaken out on either Zestlife Gap Cover options. When applying for this cover,policyholders will be required to answer an underwriting question that relatesto previous diagnosis or treatment of cancer.This cover excludes skin cancer and has a 12-month pre-existing conditionexclusion and a six-month upfront waiting period from the date of commencementof cover. Cover continues until the insured’s 65th birthday.Extended Lump SumCancer Cover AmountMonthly PremiumR100 000R92R200 000R150Premiums are valid for 2021 and may increase on 1 Feb 2022.6

MedicalPremiumWaiverCoverThe Medical Premium Waiver policyprovides cover that will continue topay your medical aid and ZestlifeGap Cover premiums in the event ofyour death or permanent disability.This cover is an additional stand-alonepolicy that enhances and extends themedical aid and gap cover premiumwaiver benefit that is embedded in theZestlife Universal Gap Cover policy.Your Zestlife Gap Cover policyembedded benefit only appliesto the Universal Gap Cover optionand will only pay out in the eventof accidental death or accidentalpermanent disability. This embeddedcover will only cover your ongoingmedical aid and Zestlife Gap Coverpremiums for a period of 12 months.The Medical Premium Waiver policyhowever pays out on death andpermanent disability, whether causedby accident or natural causes andwill pay your actual medical aid andZestlife Gap Cover premiums up to amaximum amount of R9 400 per month,for a period of either 24 or 60 months.The Medical Premium Waiver policybenefit will continue for 24 or 60Extended MedicalPremium Waiver Covermonths after the initial 12 monthbenefit that is covered under theZestlife Universal Gap Cover policy hasbeen used.This cover can be taken out asextended cover for both the ZestlifeUniversal and Zestlife Essential GapCover options.TERMS AND CONDITIONSIn the first 12 months from the date thatthe Medical Premium Waiver policycommences, no cover will be providedfor claims that arise from medicalconditions that existed in the 12 monthsprior to the policy’s commencementdate. There are also general exclusionsthat apply e.g., claims that result fromsuicide, intentional self-inflicted injuryor participation in war or crime. In thecase of a permanent disability claim,the benefit payment will commenceafter a 30 day assessment periodand will be paid for the insuredperiod or until the policyholder’srecovery, whichever occurs first. Coveris available up to age 60 for newpolicyholders and ceases for existingpolicyholders at age 70.Maximum MonthlyBenefit PaymentMonthlyPremium24 Month Cover PeriodR9 400R20360 Month Cover PeriodR9 400R357*Premiums are valid for 2021 and is subject to change on 1 Feb 2022.Underwritten by Guardrisk InsuranceCompany Limited, Guardrisk is an authorisedFinancial Services Provider.FSP Number 75.Zestlife is an authorised Financial ServicesProvider. FSP Number 37485.CONTACT USFor expert advice, please contact Zestlife on (021) 180 4220 / 0860 009 378or e-mail info@zestlife.co.za or visit www.zestlife.co.za to apply online today.7

Gap Cover is not a medical aid or a substitute for medical aid. It's a health insurance policy that provides cover for medical expense shortfalls that arise when your medical aid only covers your medical treatment costs in part. To qualify for this cover the medical aid's part payment must be paid from the medical aid hospital benefit or major