Comprehensive Gap Cover, Rated Per Policy
The widest per-policy cover in the range. Nineteen benefits reaching well beyond the hospital account into consultations, appliances, preventative care and breast reconstruction.
Comprehensive gap cover for people who want protection well beyond the hospital account, on one premium for the whole policy.
Apex carries the full in-hospital core: 500% above the medical scheme rate on specialist and hospital shortfalls, co-payments and deductibles, penalty fees, and a sub-limit enhancer of R40 000 per claim on high-cost items such as scans, prostheses and TAVI valves. BMI-related procedures are included, and robotic and computer-assisted surgery is covered.
Outside the hospital, the option reaches into everyday medical costs. Specialist and primary care consultation shortfalls are covered, appliances such as hearing aids, CPAP machines and insulin pumps carry a shortfall benefit, and preventative screenings, emergency room treatment and trauma counselling are all provided for.
The cancer suite covers co-payments, top-up cover once a scheme rand limit is reached, a R25 000 lump sum on initial diagnosis, and breast reconstruction of both the affected and the unaffected breast after mastectomy. Support benefits waive premiums and cover medical scheme contributions for six months after the accidental death or total permanent disability of the principal policyholder.
R223 000 Overall Annual Limit per insured person, per year from 1 January to 31 December. All costs must be incurred within South Africa, from a registered medical professional with a valid HPCSA practice number.
| Benefit | Limits & Details |
|---|---|
| In-Hospital Benefits | |
| Gap Cover | 500% additional above the medical scheme rate for approved in-hospital, day hospital and in-room procedures. BMI-related procedures included, limited to R5 000 per claim. Up to OAL. |
| Robotic Surgery | 500% additional on authorised robotic or computer-assisted surgical procedures, limited to R20 000 per claim. Experimental or unapproved uses excluded. Subject to OAL. |
| Co-Payments | Co-payments, including those expressed as a percentage, excesses or deductibles imposed by the medical scheme for specified procedures, hospital admission fees, scans or surgical procedures. Up to OAL. |
| Penalty Fees | R45 000 per policy per year, up to 3 claims of R15 000 each, whether the scheme charges a rand amount or a percentage. Administration charge co-payments excluded. Subject to OAL. |
| Sub-Limit Enhancer | R40 000 per claim for MRI and CT scans, cochlear implants, intraocular lenses, internal prostheses and TAVI valves. R2 000 per claim for any other sub-limit. Subject to OAL. |
| Hospital Account Shortfalls | R10 000 per policy per year, up to 4 claims of R2 500 each. Covers consumables and take-home medication scripted and dispensed by the hospital pharmacy on the day of discharge. In addition, one private room upgrade of up to R2 500 per policy per year. Subject to OAL. |
| Appliance Shortfall | R8 000 per policy per year towards shortfalls on hearing aids, wheelchairs, CPAP machines, humidifiers, insulin pumps, glucometers, nebulisers and Mirena devices, where the scheme has a defined rand limit. Appliances must be prescribed by a registered medical practitioner and purchased from an accredited supplier. Subject to OAL. |
| Emergency, Consultations & Wellness | |
| Emergency Room | R25 000 per policy per year across accident, trauma and illness. Accidents up to R2 500 per claim, at any time. Illness is covered after hours only: up to R2 500 per claim for beneficiaries aged 8 and older, or R5 000 for those younger than 8. After hours means 18h00 to 07h00 on weekdays, and all day on weekends and public holidays. Ambulance costs and follow-up visits excluded. Subject to OAL. |
| Specialist Consultations | R6 000 per policy per year, up to 4 consultations of R1 500 each, where the medical scheme has paid a portion of the consultation fee. Excludes tests, scans and charges unrelated to the consultation. Subject to OAL. |
| Primary Care Consultations | R2 000 per policy per year, up to 4 consultations of R500 each, across GPs, dentists, chiropractors, physiotherapists, biokineticists, occupational therapists, homeopaths and audiologists recognised and paid for by the medical scheme option. Subject to OAL. |
| Preventative Care | R3 000 per policy per year, up to 2 claims of R1 500 each, where the medical scheme option makes provision for the benefit. Covers the gap portion only on listed screenings and treatments. Subject to OAL. |
| Trauma Counselling | R10 000 per policy per year for counselling with a registered medical professional within six months of a qualifying traumatic incident, on provision of supporting documentation. Subject to OAL. |
| Cancer Benefits | |
| Cancer Co-Payments | Percentage co-payments on ongoing cancer treatment and biological drugs, applied once the medical scheme cancer benefit is exhausted and further treatment continues on the scheme's registered treatment plan. Only where the plan does not form part of the PMB framework. Up to OAL. |
| Cancer Top-Up | Covers ongoing treatment as per the medical scheme's registered treatment plan where the option has a defined rand limit for cancer and that limit has been reached. Only where the plan does not form part of the PMB framework. Up to OAL. |
| Initial Diagnosis of Cancer ✦ | R25 000 once-off lump sum on initial diagnosis of malignant cancer from stage 2 onwards, payable per beneficiary per lifetime, where the beneficiary is under 65 at the date of diagnosis. Skin cancer excluded, save for metastatic melanoma at stage 4. Not subject to OAL. |
| Breast Reconstruction | An additional 500% of the medical scheme rate for reconstruction of the affected breast post-mastectomy where the scheme authorises the procedure. Up to R40 000 per beneficiary for the unaffected breast, including up to R4 000 for artificial prostheses. No cover for subsequent reconstruction. Available where the beneficiary was covered at the time of the mastectomy and has kept cover since, or transferred from another gap cover provider and has been on this policy for 12 months or more without a break. Subject to OAL. |
| Support Benefits | |
| Premium Waiver ✦ | On the accidental death or total permanent disability of the principal policyholder, the premiums payable are waived for six months. Cannot be transferred, ceded or converted to cash. Not subject to OAL. |
| Medical Scheme Premium Waiver ✦ | Pays the medical scheme contribution of surviving dependants for six months, up to R3 000 per month for an individual and R6 000 per month for a family. Membership must have been active for six months prior to the event and remain active. Payable from the month after the event. Not subject to OAL. |
| Accidental Death ✦ | R10 000 paid to the nominated beneficiary on the accidental death of any insured person on the policy, on receipt of the death certificate. Not subject to OAL. |
This benefit is available on Nexus 1 and Nexus 2.
Everything needed to quote and compare Apex. The policy wording prevails over any summary.
These waiting periods apply to every plan in the range. They run from the inception date on your Schedule of Insurance.
| Waiting Period | Length & Details |
|---|---|
| General | |
| General | 3 months on a new policy, and on any dependant added later. Does not apply to claims arising from an accident. |
| Pre-existing conditions | 10 months on any condition, disease or illness that existed before inception. This includes undiagnosed conditions, and any with symptoms or earlier advice or treatment. |
| Pre-existing cancer | 12 months on all treatment related to a cancer that existed before inception. |
| Specific Benefits | |
| Pregnancy and confinement | 10 months. |
| Initial Cancer Diagnosis and Accidental Death | 3 months. |
| Total Permanent Disability and premium waivers | 6 months, where the plan includes the benefit. |
A few planned procedures have a staged waiting period. Cover rises from nothing to half, then to full.
| Months since inception | 1 to 6 | 7 to 10 | 11 onwards |
|---|---|---|---|
| Benefit paid | No benefit | 50% of the benefit | 100% of the benefit |
The staged wait does not apply to spinal, back, neck or joint procedures after an accident.
With 12 or more consecutive months of gap cover elsewhere, only a 3 month waiting period applies. It applies only to benefits your previous policy did not include.
With less than 12 months, the balance of each waiting period still applies. New benefits carry a 3 month wait.
Upgrading to a higher option follows the same rule. The 12 months count your time with X Underwriting Managers.
Open enrolment and community rating apply. Nobody is declined or charged more because of their health.
One premium covers the policy. The eldest insured person sets the age band.
Children are covered up to and including age 21, or 27 for full-time students.
Each person added to the policy serves their own waiting periods. Their Overall Annual Limit applies in full for the rest of that year.
Cover runs month to month and renews on 1 January. Cancellation needs 31 days' written notice.
This is a summary. The policy wording sets out every waiting period and exclusion in full, and prevails over this page.
One premium for the policy, with the rating age determined by the eldest insured person.
| Cover | 18 to 54 | 55 to 64 | 65 and over |
|---|---|---|---|
| Individual | R 550.00 | R 650.00 | R 1 100.00 |
| Family | R 700.00 | R 800.00 | R 1 450.00 |
| Additional child | R 50.00 | — | — |
Family cover is the principal member plus one adult dependant and up to three child dependants. Additional child dependants may be added at R50 per month.
Child dependants are covered up to age 21, or age 27 for full-time students.
The rating age, and therefore the age category, is determined by the eldest insured person.
All benefits are subject to the Overall Annual Limit of R223 000 per insured person per year (1 January to 31 December), except those marked ✦.
Premiums are reviewed and may be adjusted annually. Please refer to the policy wording for full benefit descriptions. The policy wording prevails in the event of any discrepancy.
X Underwriting Managers (Pty) Ltd is not a medical scheme and does not pay claims that are the obligation of a medical scheme.
Monthly premiums for four common households on all four plans, at current rates.
Shading marks the lower premium in each pairing: Nexus 1 with Vertex, Nexus 2 with Apex. Benefits differ within each pairing, so compare the schedules too. Which rating model usually costs less?
Speak to your broker or contact us directly for a quote on the Apex option.