From in-hospital specialist shortfalls to cancer diagnosis payouts, X Gap Cover protects you and your family at every stage of the healthcare journey.
South African medical aids pay specialists and hospitals at their own rate, often significantly less than what providers actually charge. The difference, your shortfall, is billed directly to you.
X Gap Cover pays towards that shortfall, protecting you from unexpected out-of-pocket costs when you need hospital care most.
Example is illustrative. Actual payments subject to policy limits and terms.
From in-hospital shortfalls to cancer diagnosis payouts, our benefit suite is designed to protect you and your family at every stage of the healthcare journey.
Two plans designed to protect you and your family from unexpected medical shortfalls, both with full access to our comprehensive benefit suite.
A full side-by-side breakdown of every benefit and limit across both plans.
| Benefit | Apex | Vertex |
|---|---|---|
| In-Hospital | ||
| Gap Cover (additional) | 500% | 500% |
| BMI-Related Procedures (per claim) | R 5 000.00 | — |
| Robotic Surgery (per claim) | R 20 000.00 | — |
| Co-Payments | Up to OAL | Up to OAL |
| Penalty Fee (3 per policy per annum) | R 15 000.00 | R 15 000.00 |
|
Sub-Limit Enhancer, R40 000 per claim for: · MRI and CT scans · Cochlear implants · Intraocular lenses · Internal prostheses · Transcatheter Aortic Valve Implantation (TAVI) valves Any other sub-limit: R2 000 per claim. |
R 40 000.00 R 2 000.00 |
R 40 000.00 R 2 000.00 |
| Hospital Account Shortfall (4 per policy per annum) | R 2 500.00 | R 2 500.00 |
| Private Room Upgrades (1 per policy per annum) | R 2 500.00 | R 2 500.00 |
| Appliance Shortfall Benefit | R 8 000.00 | — |
| Emergency Room | ||
| Emergency Room, Annual Sub-Limit per policy per annum | R 25 000.00 | R 20 000.00 |
| Emergency Room, Accident (per claim, subject to sub-limit) | R 2 500.00 | R 2 500.00 |
| Emergency Room, Illness 8 years and older (per claim, subject to sub-limit) | R 2 500.00 | R 2 500.00 |
| Emergency Room, Illness younger than 8 years (per claim, subject to sub-limit) | R 5 000.00 | R 5 000.00 |
| Day-to-Day | ||
| Specialist Consultations (4 per policy per annum) | R 1 500.00 | — |
| Primary Care Consultations (4 per policy per annum) | R 500.00 | — |
| Preventative Care (2 per policy per annum) | R 1 500.00 | — |
| Trauma Counselling (limit per policy) | R 10 000.00 | — |
| Cancer | ||
| Cancer Co-Payment | Up to OAL | Up to OAL |
| Cancer Top-Up | Up to OAL | Up to OAL |
| Initial Diagnosis (1 per beneficiary, lifetime limit, Stage 2 and above, diagnosed younger than 65) | R 25 000.00 | R 25 000.00 |
| Reconstruction of Affected Breast (1 per beneficiary, lifetime limit) | Additional 500% | — |
| Reconstruction of Unaffected Breast (1 per beneficiary, lifetime limit) | R 40 000.00 | — |
| Breast Prosthesis (sub-limit) | R 4 000.00 | — |
| Value-Added Benefits | ||
| Premium Waiver | 6 Months | 6 Months |
| Accidental Death | R 10 000.00 | R 8 000.00 |
| Medical Scheme Premium Cover, Individuals (6 months) | R 3 000.00 | — |
| Medical Scheme Premium Cover, Families (6 months) | R 6 000.00 | — |
| Monthly Premiums | ||
| Individual, aged 18 to 54 | R 550.00 | R 450.00 |
| Family, aged 18 to 54 | R 700.00 | R 560.00 |
| Individual, aged 55 to 64 | R 650.00 | R 550.00 |
| Family, aged 55 to 64 | R 800.00 | R 700.00 |
| Individual, aged 65 and above | R 1 100.00 | R 950.00 |
| Family, aged 65 and above | R 1 450.00 | R 1 150.00 |
| Additional Child (from child 4 onwards) | R 50.00 | R 40.00 |
Information is subject to change. Premiums are reviewed and may be adjusted annually.
A broker will assess your medical aid option, your lifestyle, and your family's needs, then recommend the plan that is right for you.