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 annum from 1 April 2026. 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 | Up to R15 000 per claim, 3 claims per policy per annum, 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 | R2 500 per claim, 4 claims per policy per annum. Covers consumables and take-home medication scripted and dispensed by the hospital pharmacy on the day of discharge. Includes one private room upgrade of R2 500 per policy per annum. Subject to OAL. |
| Appliance Shortfall | R8 000 per policy per annum 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 annum across accident, trauma and illness. R2 500 per claim for accident-related events and for illness events for beneficiaries 8 and older, after hours only. R5 000 per claim for beneficiaries younger than 8. Ambulance costs and follow-up visits excluded. Subject to OAL. |
| Specialist Consultations | R1 500 per consultation, 4 claims per policy per annum, 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 | R500 per consultation, 4 claims per policy per annum 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 | R1 500 per claim, 2 claims per policy per annum, 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 annum 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. 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.
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. Further adults cannot be added to the policy.
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 annum from 1 April 2026, 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.
Speak to your broker or contact us directly for a quote on the Apex option.