Benefits | X Underwriting

Benefit overview

Four Plans, Two Rating Models

Nexus 1, Nexus 2, Vertex and Apex all protect you from the most common and costly medical shortfalls faced by South Africans with private medical aid. Every plan carries the same Overall Annual Limit of R223 000 per insured person per annum and the same 500% in-hospital gap benefit.

Read every limit together with its unit. On Nexus 1 and Nexus 2, limits and claim counts apply per insured person unless the benefit states otherwise, so the same rand figure goes further on a family. On Vertex and Apex, they apply per policy.

Total Benefits

Categories

Plans

Additional 500%

Gap Benefit

R223K

Limit, Per Insured Person

R113+

From, Per Adult Life

Nexus 1 Nexus 2 Vertex Apex Not included

In-Hospital

7 benefits

Benefit

Nexus 1per person

Nexus 2per person

Vertexper policy

Apexper policy

Gap Cover 500% additional above the medical scheme rate for in-hospital, day hospital and in-room procedures.

500% up to OAL

BMI-Related Procedures Additional charges for the management of overweight or underweight patients (BMI codes 0018 and 0019).

Not included

R5 000 per claim

Not included

R5 000 per claim

Robotic Surgery Shortfalls on authorised robotic or computer-assisted surgical procedures. Experimental uses excluded.

Not included

500% up to R20 000

Not included

500% up to R20 000

Co-Payments Co-payments, excesses and deductibles imposed by your scheme for specified procedures, admission fees, scans or surgery.

Up to OAL

Penalty Fees Network penalty for voluntary use of a non-designated or partial cover hospital. Administration charge co-payments excluded.

R15 000 · 1 claim

R15 000 · 3 claims

Sub-Limit Enhancer MRI and CT scans, cochlear implants, intraocular lenses, internal prostheses, TAVI valves. R2 000 for any other sub-limit.

R20 000 / R2 000
R20 000 aggregate

R40 000 / R2 000
R40 000 aggregate

R40 000 / R2 000

Hospital Account Shortfalls Consumables and take-home medication dispensed by the hospital pharmacy on the day of discharge.

R2 000 · 2 claims

R2 500 · 4 claims

Private Room Upgrade Included within the Hospital Account Shortfall benefit, one per annum on every plan.

R2 000

R2 500

Appliance Shortfall Hearing aids, wheelchairs, CPAP machines, humidifiers, insulin pumps, glucometers, nebulisers and Mirena devices.

Not included

R5 000 p/a

Not included

R8 000 p/a

Emergency Room

1 benefit

Benefit

Nexus 1per person

Nexus 2per person

Vertexper policy

Apexper policy

Emergency Room, Annual Sub-Limit Total annual sub-limit across accident, trauma and illness. Ambulance costs and follow-up visits excluded.

R4 000 p/a

R5 000 p/a

R20 000 p/a

R25 000 p/a

Emergency Room, Accident Costs directly related to the initial accidental event. Subject to the annual sub-limit.

R2 000 per claim

R2 500 per claim

Emergency Room, Illness (8 and older) Illness-related visits for beneficiaries aged 8 and older, after hours only. Subject to the annual sub-limit.

R2 000 per claim

R2 500 per claim

Emergency Room, Illness (younger than 8) Illness-related visits for beneficiaries younger than 8 years. Subject to the annual sub-limit.

R4 000 per claim

R5 000 per claim

Consultations & Wellness

4 benefits

Benefit

Nexus 1per person

Nexus 2per person

Vertexper policy

Apexper policy

Specialist Consultations The shortfall on a specialist consultation fee where the scheme has paid a portion. Excludes tests and scans.

Not included

R1 000 · 2 claims

Not included

R1 500 · 4 claims

Primary Care Consultations GPs, dentists, chiropractors, physiotherapists, biokineticists, occupational therapists, homeopaths and audiologists.

Not included

R500 · 2 claims
combined

Not included

R500 · 4 claims

Preventative Care The gap portion on pap smears, cholesterol and glucose tests, flu vaccination, immunisation, bone density scans, PSA tests and mammograms.

R1 000 · 1 claim

R1 500 · 1 claim

Not included

R1 500 · 2 claims

Trauma Counselling Counselling within six months of a qualifying traumatic incident, including dread disease, hijacking and violent crime.

R3 000 p/a

R5 000 p/a

Not included

R10 000 p/a

Cancer

4 benefits

Benefit

Nexus 1per person

Nexus 2per person

Vertexper policy

Apexper policy

Cancer Co-Payments Co-payments on ongoing treatment and biological drugs once the scheme cancer benefit is exhausted, on the registered treatment plan.

Up to OAL

Cancer Top-Up Continued cover for treatment on the scheme's registered treatment plan once a defined rand limit for cancer has been reached.

Up to OAL

Initial Diagnosis of Cancer ✦ Once-off lump sum on a first diagnosis from stage 2 onwards, before age 65, per beneficiary per lifetime. Not subject to the OAL.

R20 000 lump sum

R25 000 lump sum

Breast Reconstruction After mastectomy: affected breast at an additional 500%, unaffected breast up to R40 000 including R4 000 for prostheses.

Not included

+500% / R40 000

Not included

+500% / R40 000

Support Benefits

4 benefits

Benefit

Nexus 1per person

Nexus 2per person

Vertexper policy

Apexper policy

Premium Waiver ✦ Premiums waived for six months on the accidental death or total permanent disability of the principal policyholder. Not subject to the OAL.

6 months
all remaining lives

6 months

Medical Scheme Premium Waiver ✦ Pays the medical scheme contribution of surviving dependants for six months, subject to a monthly cap for the policy as a whole.

Max R6 000 p/m
per policy

Max R7 500 p/m
per policy

Not included

R3 000 individual
R6 000 family

Accidental Death ✦ Paid to the nominated beneficiary on the accidental death of any insured person, on receipt of the death certificate. Not subject to the OAL.

R10 000

R15 000

R8 000

R10 000

Newborn ✦ Lump sum per newborn baby, paid when the baby is registered on the gap policy within 90 days of birth. Subject to the pregnancy and confinement waiting period. Not subject to the OAL.

R2 000 per baby

Not included

How to read these tables

✦ Benefits marked are not subject to the Overall Annual Limit. All other benefits are subject to the OAL of R223 000 per insured person per annum from 1 April 2026.
Nexus 1 and Nexus 2 limits and claim counts are stated per insured person per annum. Vertex and Apex limits and claim counts are stated per policy per annum. The Medical Scheme Premium Waiver monthly cap is the one exception: it applies to the policy as a whole on all four plans.
Emergency Room illness claims are after hours only for beneficiaries older than 8. The higher per-claim figure applies to beneficiaries younger than 8.
Information is subject to change. Please refer to the policy wording for full benefit descriptions. The policy wording prevails in the event of any discrepancy.

Your Benefits, At a Glance

Four Plans, Two Rating Models

Don't Pay the Shortfall
Out of Your Own Pocket

Your Benefits, At a Glance

Four Plans, Two Rating Models

Don't Pay the ShortfallOut of Your Own Pocket

Don't Pay the Shortfall
Out of Your Own Pocket