Gap Cover | X Underwriting

How the range works

Two Ways to Be Rated

The four plans divide into two families. The difference is not only what is covered, but how the premium is calculated and how every limit is applied.

Rated per life

Nexus 1 & Nexus 2

The new-generation options. A separate premium is charged for each insured person on the Schedule of Insurance, based on the age band that person actually falls into.

Nobody carries the cost of another age band. A younger member is never priced on an older member's rate.
No distinction between the principal member and an adult dependant. Each life is simply rated on its own.
Rand limits and claim counts apply per insured person per annum. A two-claim benefit is two claims each. The Medical Scheme Premium Waiver is the one exception, capped per policy.
The policyholder remains the sole contracting party and is liable for the total premium payable.

Nexus 1 · 15 benefits · From R113 p/m per adult life Nexus 2 · 20 benefits · From R130 p/m per adult life

Rated per policy

Vertex & Apex

Our traditional gap cover options. One premium is charged for the policy as a whole, on an individual or family rate, with the rating age determined by the eldest insured person.

The eldest life sets the age band for everybody on the policy.
Family cover is the principal member plus one adult dependant and up to three child dependants. Additional children may be added at R40 on Vertex and R50 on Apex.
Rand limits and claim counts apply per policy. A four-claim benefit is four claims for the policy, not four each.
Child dependants are covered to age 21, or 27 for full-time students.

Vertex · 11 benefits · From R450 p/m Apex · 19 benefits · From R550 p/m

Why this matters when you compare limits. The same rand figure is not worth the same under each model. A R2 000 Hospital Account Shortfall benefit with two claims applies to the policy as a whole on Vertex and Apex, but to each insured person on Nexus 1 and Nexus 2. On a family of three, that is the difference between two claims and six. Always read a limit together with the unit it is stated in.

Which Model Usually Costs Less?

A quick guide for client conversations, based on current rates. The calculator gives the exact figure.

Everyone under 55

Nexus usually costs less

Adults under 55 sit in low age bands, well below a family rate.

Couples, both 55 or older

Vertex and Apex usually cost less

One family rate covers both lives. On Nexus, each older life pays its own higher band.

Single members

Nexus usually costs less

The exception is ages 60 to 64, where Vertex and Apex come out slightly lower.

Mixed-age couples

It depends on the ages

One partner over 55 can tip it either way. Use the calculator for the exact premium.

Price is only half of the trade-off. Nexus limits apply to each person, so a bigger household gets more claims in total. Vertex and Apex limits are shared, so one person can use the whole allowance. See the worked examples below.

Plans

Choose the Right Plan for You

Four plans, grouped by how they are rated. All four carry the same Overall Annual Limit of R223 000 per insured person per annum and the same 500% in-hospital gap benefit.

New-Generation Gap Cover

Rated per life

A separate premium for each insured person, on their own age band. Limits and claim counts apply per insured person unless the benefit states otherwise.

Essential Gap Cover · 15 benefits

NEXUS 1

Core protection against the shortfalls that create the largest and most frequent bills, at a premium that reflects your own age.

R113 /month

Per adult life, aged 22 to 24 · From

✓ Gap Cover (500% additional)
✓ Co-Payments (up to OAL)
✓ Penalty Fees (R15 000 · 1 claim each)
✓ Sub-Limit Enhancer (R20 000 / R2 000)
✓ Hospital Account Shortfalls (R2 000 · 2 claims each)
✓ Private Room Upgrade (R2 000 · 1 each per annum)
✓ Emergency Room (R4 000 each per annum)
✓ Preventative Care (R1 000 each)
✓ Trauma Counselling (R3 000 each)
✓ Cancer Co-Payments & Top-Up (up to OAL)
✓ Initial Cancer Diagnosis (R20 000)
✓ Premium Waiver (6 months)
✓ Medical Scheme Premium Waiver (max R6 000 p/m)
✓ Accidental Death (R10 000)
✓ Newborn (R2 000 per baby)

View Full Plan

Get a Quote · Brochure ↓

Enhanced Gap Cover · 20 benefits

Cover that goes beyond the gap

Twenty benefits across the range. Nexus 1 and Nexus 2 limits are stated per insured person; Vertex and Apex limits are stated per policy.

In-Hospital

Gap Cover

Covers the difference between the medical scheme rate and what service providers charge for approved in-hospital, day hospital and in-room procedures.

All four plans · 500% additional, up to OAL Nexus 2 & Apex · BMI up to R5 000 per claim Nexus 1 & Vertex · BMI excluded

In-Hospital

Robotic Surgery

Shortfalls on authorised robotic or computer-assisted surgical procedures. Experimental or unapproved uses of robotic technology are excluded.

Nexus 2 · 500% up to R20 000 per claim Apex · 500% up to R20 000 per claim Nexus 1 & Vertex · Not included

In-Hospital

Co-Payments

Co-payments, including those expressed as a percentage, excesses or deductibles imposed by your medical scheme for specified procedures, hospital admission fees, scans or surgical procedures.

All four plans · Up to OAL

In-Hospital

Penalty Fees

Covers the penalty fee charged for the voluntary use of a non-designated or partial cover network hospital, whether the scheme charges a rand amount or a percentage. Administration charge co-payments excluded.

All four plans · R15 000 per claim Nexus 1 & 2 · R15 000 per person per year · 1 claim Vertex & Apex · R45 000 per policy per year · 3 claims of R15 000

In-Hospital

Sub-Limit Enhancer

Covers shortfalls when scheme sub-limits are exceeded for MRI and CT scans, cochlear implants, intraocular lenses, internal prostheses and TAVI valves. Any other sub-limit is covered to R2 000 per claim.

Nexus 1 · R20 000 specified, R20 000 p/a aggregate Nexus 2 · R40 000 specified, R40 000 p/a aggregate Vertex & Apex · R40 000 specified

In-Hospital

Hospital Account Shortfalls

Shortfalls on the hospital account for items such as consumables, and take-home medication scripted and dispensed by the hospital pharmacy on the day of discharge. Each plan also covers one private room upgrade a year, in addition to these claims.

Nexus 1 & 2 · R4 000 per person per year · 2 claims of R2 000 · plus 1 room upgrade each Vertex & Apex · R10 000 per policy per year · 4 claims of R2 500 · plus 1 room upgrade

Appliances

Appliance Shortfall

Shortfalls on hearing aids, wheelchairs, CPAP machines, humidifiers, insulin pumps, glucometers, nebulisers and Mirena devices, where the scheme has a defined rand limit.

Nexus 2 · R5 000 each p/a Apex · R8 000 p/a Nexus 1 & Vertex · Not included

Emergency

Emergency Room

Costs directly related to the initial emergency event at a registered casualty facility. Illness claims are covered after hours only, with a higher limit for children younger than 8. Ambulance costs and follow-up visits excluded.

Nexus 1 · R4 000 each p/a Nexus 2 · R5 000 each p/a Vertex · R20 000 p/a Apex · R25 000 p/a

Out of Hospital

Specialist Consultations

The shortfall on a specialist consultation fee where the scheme has paid a portion. Excludes tests, scans and any charges unrelated to the consultation.

Nexus 2 · R2 000 per person per year · 2 claims of R1 000 Apex · R6 000 per policy per year · 4 claims of R1 500 Nexus 1 & Vertex · Not included

Out of Hospital

Primary Care Consultations

Day-to-day visits: GPs, dentists, chiropractors, physiotherapists, biokineticists, occupational therapists, homeopaths and audiologists recognised and paid for by your medical scheme option.

Nexus 2 · R1 000 per person per year · 2 claims of R500 Apex · R2 000 per policy per year · 4 claims of R500 Nexus 1 & Vertex · Not included

Wellness

Preventative Care

The gap portion on pap smears, cholesterol and blood glucose tests, flu vaccination, childhood immunisation, bone density scans, PSA tests, mammograms and contraceptive implantation.

Nexus 1 · R1 000 per person per year · 1 claim Nexus 2 · R1 500 per person per year · 1 claim Apex · R3 000 per policy per year · 2 claims of R1 500 Vertex · Not included

Mental Health

Trauma Counselling

Counselling with a registered medical professional within six months of a qualifying traumatic incident, including dread disease diagnosis, hijacking and violent crime.

Nexus 1 · R3 000 each p/a Nexus 2 · R5 000 each p/a Apex · R10 000 p/a Vertex · Not included

Cancer

Cancer Co-Payments

Percentage co-payments on ongoing cancer treatment and biological drugs, applied once the medical scheme cancer benefit is exhausted and treatment continues on the registered treatment plan.

All four plans · Up to OAL

Cancer

Cancer Top-Up

Covers ongoing treatment as per the scheme's registered treatment plan where the option has a defined rand limit for cancer and that limit has been reached.

All four plans · Up to OAL

Cancer

Initial Diagnosis of Cancer

Once-off lump sum on a first diagnosis of malignant cancer from stage 2 onwards, where the beneficiary is under 65 at the date of diagnosis. Skin cancer excluded, save for metastatic melanoma at stage 4. Not subject to the OAL.

Nexus 1 · R20 000 lump sum Nexus 2, Vertex & Apex · R25 000 lump sum

Cancer

Breast Reconstruction

An additional 500% of the scheme rate for reconstruction of the affected breast post-mastectomy, plus reconstruction of the unaffected breast including artificial prostheses. No cover for subsequent reconstruction. Cover depends on being insured at the time of the mastectomy, or on 12 months of unbroken cover after a transfer.

Nexus 2 & Apex · +500% affected · R40 000 unaffected, incl. R4 000 prosthesis Nexus 1 & Vertex · Not included

Support

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 the OAL.

All four plans · 6 months Nexus 1 & 2 · Waived for all remaining insured persons

Support

Medical Scheme Premium Waiver

Pays an amount equal to the medical scheme contribution of surviving dependants for six months after the event, subject to a monthly cap for the policy as a whole. Not subject to the OAL.

Nexus 1 · Max R6 000 p/m per policy Nexus 2 · Max R7 500 p/m per policy Apex · R3 000 p/m individual, R6 000 p/m family Vertex · Not included

Support

Accidental Death

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 the OAL.

Nexus 1 · R10 000 once-off Nexus 2 · R15 000 once-off Vertex · R8 000 once-off Apex · R10 000 once-off

Family

Newborn

Lump sum per newborn baby, payable when the baby is registered on the gap policy within 90 days of birth. A stated benefit to cover costs unrelated to medical expenses. Subject to the waiting period for pregnancy and confinement. Not subject to the OAL.

Nexus 1 & 2 · R2 000 per baby Vertex & Apex · Not included

Benefit comparison

Compare All Benefits

Compare within a family, where limits share the same unit, or across all four at once. The Overall Annual Limit is R223 000 per insured person per year (1 January to 31 December) on every plan, including Vertex and Apex.

Rated per life. Every rand limit and claim count below applies per insured person per year unless the row states otherwise. The policy premium is the sum of the premiums for everyone on the Schedule of Insurance.

Benefit	Nexus 1	Nexus 2
In-Hospital
Gap Cover (additional)	500%	500%
BMI-Related Procedures (per claim)	—	R 5 000.00
Robotic Surgery (500% additional, per claim)	—	R 20 000.00
Co-Payments	Up to OAL	Up to OAL
Penalty Fees, per insured person per year	R 15 000.001 claim	R 15 000.001 claim
Sub-Limit Enhancer, per claim for: · MRI and CT scans · Cochlear implants · Intraocular lenses · Internal prostheses · Transcatheter Aortic Valve Implantation (TAVI) valves Any other sub-limit.	R 20 000.00 R 2 000.00	R 40 000.00 R 2 000.00
Sub-Limit Enhancer, annual aggregate per insured person	R 20 000.00	R 40 000.00
Hospital Account Shortfalls, per insured person per year	R 4 000.002 claims of R 2 000.00	R 4 000.002 claims of R 2 000.00
Private Room Upgrade (1 per insured person per annum)	R 2 000.00	R 2 000.00
Appliance Shortfall Benefit (per insured person per annum)	—	R 5 000.00
Emergency Room
Emergency Room, annual sub-limit per insured person	R 4 000.00	R 5 000.00
Emergency Room, accident (per claim)	R 2 000.00	R 2 500.00
Emergency Room, illness, aged 8 and older (per claim, after hours)	R 2 000.00	R 2 500.00
Emergency Room, illness, younger than 8 (per claim, after hours)	R 4 000.00	R 5 000.00
Consultations & Wellness
Specialist Consultations, per insured person per year	—	R 2 000.002 claims of R 1 000.00
Primary Care Consultations, per insured person per year	—	R 1 000.002 claims of R 500.00, combined
Preventative Care, per insured person per year	R 1 000.001 claim	R 1 500.001 claim
Trauma Counselling (per insured person per annum)	R 3 000.00	R 5 000.00
Cancer
Cancer Co-Payments	Up to OAL	Up to OAL
Cancer Top-Up	Up to OAL	Up to OAL
Initial Cancer Diagnosis ✦ (stage 2+, before age 65)	R 20 000.00	R 25 000.00
Reconstruction of Affected Breast	—	Additional 500%
Reconstruction of Unaffected Breast	—	R 40 000.00
Breast Prosthesis (sub-limit)	—	R 4 000.00
Support Benefits
Premium Waiver ✦ (all remaining insured persons)	6 Months	6 Months
Medical Scheme Premium Waiver ✦, principal member (per month)	R 2 000.00	R 2 500.00
Medical Scheme Premium Waiver ✦, adult dependant (per month)	R 1 750.00	R 2 000.00
Medical Scheme Premium Waiver ✦, child dependant (per month)	R 750.00	R 1 000.00
Medical Scheme Premium Waiver ✦, policy cap (per month)	R 6 000.00	R 7 500.00
Accidental Death ✦	R 10 000.00	R 15 000.00
Newborn ✦ (per baby, registered within 90 days of birth)	R 2 000.00	R 2 000.00
Monthly Premiums, Per Insured Person
Age 0 to 21	R 30.00	R 50.00
Age 22 to 24	R 113.00	R 130.00
Age 25 to 34	R 140.00	R 161.00
Age 35 to 44	R 157.00	R 181.00
Age 45 to 54	R 184.00	R 212.00
Age 55 to 59	R 420.00	R 483.00
Age 60 to 64	R 580.00	R 667.00
Age 65 and over	R 730.00	R 840.00

Rated per policy. Every rand limit and claim count below applies per policy per year. The rating age is determined by the eldest insured person.

Benefit	Vertex	Apex
In-Hospital
Gap Cover (additional)	500%	500%
BMI-Related Procedures (per claim)	—	R 5 000.00
Robotic Surgery (500% additional, per claim)	—	R 20 000.00
Co-Payments	Up to OAL	Up to OAL
Penalty Fees, per policy per year	R 45 000.003 claims of R 15 000.00	R 45 000.003 claims of R 15 000.00
Sub-Limit Enhancer, per claim for: · MRI and CT scans · Cochlear implants · Intraocular lenses · Internal prostheses · Transcatheter Aortic Valve Implantation (TAVI) valves Any other sub-limit.	R 40 000.00 R 2 000.00	R 40 000.00 R 2 000.00
Hospital Account Shortfalls, per policy per year	R 10 000.004 claims of R 2 500.00	R 10 000.004 claims of R 2 500.00
Private Room Upgrade (1 per policy per annum)	R 2 500.00	R 2 500.00
Appliance Shortfall Benefit (per annum)	—	R 8 000.00
Emergency Room
Emergency Room, annual sub-limit per policy	R 20 000.00	R 25 000.00
Emergency Room, accident (per claim)	R 2 500.00	R 2 500.00
Emergency Room, illness, aged 8 and older (per claim, after hours)	R 2 500.00	R 2 500.00
Emergency Room, illness, younger than 8 (per claim, after hours)	R 5 000.00	R 5 000.00
Consultations & Wellness
Specialist Consultations, per policy per year	—	R 6 000.004 claims of R 1 500.00
Primary Care Consultations, per policy per year	—	R 2 000.004 claims of R 500.00
Preventative Care, per policy per year	—	R 3 000.002 claims of R 1 500.00
Trauma Counselling (per policy per annum)	—	R 10 000.00
Cancer
Cancer Co-Payments	Up to OAL	Up to OAL
Cancer Top-Up	Up to OAL	Up to OAL
Initial Diagnosis of Cancer ✦ (stage 2+, before age 65)	R 25 000.00	R 25 000.00
Reconstruction of Affected Breast	—	Additional 500%
Reconstruction of Unaffected Breast	—	R 40 000.00
Breast Prosthesis (sub-limit)	—	R 4 000.00
Support Benefits
Premium Waiver ✦	6 Months	6 Months
Medical Scheme Premium Waiver ✦, individual (per month, for 6 months)	—	R 3 000.00
Medical Scheme Premium Waiver ✦, family (per month, for 6 months)	—	R 6 000.00
Accidental Death ✦	R 8 000.00	R 10 000.00
Monthly Premiums, Per Policy
Individual, aged 18 to 54	R 450.00	R 550.00
Family, aged 18 to 54	R 560.00	R 700.00
Individual, aged 55 to 64	R 550.00	R 650.00
Family, aged 55 to 64	R 700.00	R 800.00
Individual, aged 65 and above	R 950.00	R 1 100.00
Family, aged 65 and above	R 1 150.00	R 1 450.00
Additional child (from child 4 onwards)	R 40.00	R 50.00

Read the unit, not just the figure. Nexus 1 and Nexus 2 limits below are stated per insured person. Vertex and Apex limits are stated per policy. Identical rand amounts are therefore not equivalent across the two families. The one exception is the Medical Scheme Premium Waiver monthly cap, which applies to the policy as a whole on every plan that includes it and is marked as such in the table. Premiums are excluded from this view because they are not calculated on the same basis. Use the premium calculator instead.

Benefit	Nexus 1per person	Nexus 2per person	Vertexper policy	Apexper policy
In-Hospital
Gap Cover (additional)	500%	500%	500%	500%
BMI-Related Procedures (per claim)	—	R 5 000.00	—	R 5 000.00
Robotic Surgery (500% additional, per claim)	—	R 20 000.00	—	R 20 000.00
Co-Payments	Up to OAL	Up to OAL	Up to OAL	Up to OAL
Penalty Fees, per year	R 15 000.001 claim	R 15 000.001 claim	R 45 000.003 claims of R 15 000.00	R 45 000.003 claims of R 15 000.00
Sub-Limit Enhancer, specified items (per claim)	R 20 000.00	R 40 000.00	R 40 000.00	R 40 000.00
Sub-Limit Enhancer, any other sub-limit (per claim)	R 2 000.00	R 2 000.00	R 2 000.00	R 2 000.00
Sub-Limit Enhancer, annual aggregate	R 20 000.00	R 40 000.00	—	—
Hospital Account Shortfalls, per year	R 4 000.002 claims of R 2 000.00	R 4 000.002 claims of R 2 000.00	R 10 000.004 claims of R 2 500.00	R 10 000.004 claims of R 2 500.00
Private Room Upgrade (1 per annum)	R 2 000.00	R 2 000.00	R 2 500.00	R 2 500.00
Appliance Shortfall Benefit (per annum)	—	R 5 000.00	—	R 8 000.00
Emergency Room
Emergency Room, annual sub-limit	R 4 000.00	R 5 000.00	R 20 000.00	R 25 000.00
Emergency Room, accident (per claim)	R 2 000.00	R 2 500.00	R 2 500.00	R 2 500.00
Emergency Room, illness, aged 8 and older (per claim, after hours)	R 2 000.00	R 2 500.00	R 2 500.00	R 2 500.00
Emergency Room, illness, younger than 8 (per claim, after hours)	R 4 000.00	R 5 000.00	R 5 000.00	R 5 000.00
Consultations & Wellness
Specialist Consultations, per year	—	R 2 000.002 claims of R 1 000.00	—	R 6 000.004 claims of R 1 500.00
Primary Care Consultations, per year	—	R 1 000.002 claims of R 500.00, combined	—	R 2 000.004 claims of R 500.00
Preventative Care, per year	R 1 000.001 claim	R 1 500.001 claim	—	R 3 000.002 claims of R 1 500.00
Trauma Counselling (per annum)	R 3 000.00	R 5 000.00	—	R 10 000.00
Cancer
Cancer Co-Payments	Up to OAL	Up to OAL	Up to OAL	Up to OAL
Cancer Top-Up	Up to OAL	Up to OAL	Up to OAL	Up to OAL
Initial Diagnosis of Cancer ✦	R 20 000.00	R 25 000.00	R 25 000.00	R 25 000.00
Reconstruction of Affected Breast	—	Additional 500%	—	Additional 500%
Reconstruction of Unaffected Breast	—	R 40 000.00	—	R 40 000.00
Breast Prosthesis (sub-limit)	—	R 4 000.00	—	R 4 000.00
Support Benefits
Premium Waiver ✦	6 Months	6 Months	6 Months	6 Months
Medical Scheme Premium Waiver ✦, monthly cap Per policy on every plan that includes it, not per insured person.	R 6 000.00	R 7 500.00	—	R 3 000.00 individual R 6 000.00 family
Accidental Death ✦	R 10 000.00	R 15 000.00	R 8 000.00	R 10 000.00
Newborn ✦ (per baby)	R 2 000.00	R 2 000.00	—	—
At a Glance
Total benefits	15	20	11	19
Overall Annual Limit Per insured person per annum on all four plans, including Vertex and Apex.	R 223 000.00	R 223 000.00	R 223 000.00	R 223 000.00

Terms and Conditions

Information is subject to change. Premiums are reviewed and may be adjusted annually. The policy wording prevails in the event of any discrepancy.

✦ 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 year (1 January to 31 December).
On Vertex and Apex, the rating age is determined by the eldest insured person, and limits and claim counts apply per policy per annum.
Vertex and Apex family cover allows for the principal member, 1 adult dependant and 3 child dependants^*. Additional child dependants may be added at R40 on Vertex and R50 on Apex.
On Nexus 1 and Nexus 2, a separate premium is charged for each insured person, with no distinction between the principal member and an adult dependant. Every limit and claim count applies per insured person per annum unless the benefit states otherwise; the Medical Scheme Premium Waiver is capped per policy.
Emergency Room illness claims are covered after hours only, at any age. After hours means 18h00 to 07h00 on weekdays, and all day on weekends and public holidays. The higher per-claim limit applies to beneficiaries younger than 8.
Costs must be incurred within the borders of South Africa, from a registered medical professional with a valid practice number issued by the HPCSA.
^* Any dependant covered on either the principal or adult dependant medical aid up to the age of 21.^**
^** Full-time students covered on either the principal or adult dependant medical aid may be included as a child dependant up to the age of 27.

Comprehensive Cover for Every Medical Shortfall

What Is Gap Cover?

Two Ways to Be Rated

Which Model Usually Costs Less?

What Households Pay

Choose the Right Plan for You

What Would Your Policy Cost?

Cover that goes beyond the gap

Compare All Benefits