Essential Gap Cover, Priced Per Life
A new generation of gap cover. Core protection against in-hospital shortfalls, co-payments, emergency treatment and cancer costs, priced per life so that every member pays the lowest premium their own age allows.
Essential gap cover for people who want the shortfalls that matter most taken care of, at a premium that reflects their own age rather than a blended family rate.
The Nexus 1 option is built around the shortfalls that create the largest and most frequent bills: the difference between what your medical scheme pays and what specialists and hospitals actually charge in hospital, the co-payments and deductibles your scheme imposes, and the penalty fees applied when you use a hospital outside the network.
Beyond the hospital, the option extends to emergency room treatment, preventative screenings, trauma counselling and a full suite of cancer benefits, including co-payments, top-up cover once a scheme limit is reached, and a lump sum on initial diagnosis.
Support benefits carry the policy through the events a family cannot plan for. Premiums are waived for six months on the accidental death or total permanent disability of the principal policyholder, the medical scheme contribution of surviving dependants is covered over the same period, and an accidental death benefit is paid to the nominated beneficiary. A newborn benefit pays a lump sum for each new baby registered on the policy within 90 days of birth.
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 excluded. Up 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 | R15 000 per insured person per year, as a single claim, whether the scheme charges a rand amount or a percentage. Administration charge co-payments excluded. Subject to OAL. |
| Sub-Limit Enhancer | R20 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. Limited to R20 000 per insured person per annum in aggregate. Subject to OAL. |
| Hospital Account Shortfalls | R4 000 per insured person per year, up to 2 claims of R2 000 each, covering 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 000 per insured person per year. Subject to OAL. |
| Emergency & Wellness | |
| Emergency Room | R4 000 per insured person per year across accident, trauma and illness. Accidents up to R2 000 per claim, at any time. Illness is covered after hours only: up to R2 000 per claim for beneficiaries aged 8 and older, or R4 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. |
| Preventative Care | R1 000 per insured person per year, as a single claim, 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 | R3 000 per insured person 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 Cancer Diagnosis ✦ | R20 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. |
| Support Benefits | |
| Premium Waiver ✦ | On the accidental death or total permanent disability of the principal policyholder, the premiums payable for all remaining insured persons 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: R2 000 per month for the principal member, R1 750 for each adult dependant and R750 for each child dependant, limited to R6 000 per month for the policy as a whole. 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. |
| Newborn ✦ | R2 000 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 set out in the Policy Wording. Not subject to OAL. |
These benefits are available on other options in the range.
Everything needed to quote and compare Nexus 1. 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.
Each person is priced on their own age band. Bands are set at inception and reset each 1 January.
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.
Each insured person is priced on their own age band. There is no separate individual or family rate, and no distinction between the principal member and an adult dependant. The policy premium is the sum of the premiums for everyone listed on the Schedule of Insurance.
| Age Band | Lower Age | Upper Age | Monthly Premium |
|---|---|---|---|
| 0 to 21 | 0 | 21 | R 30.00 |
| 22 to 24 | 22 | 24 | R 113.00 |
| 25 to 34 | 25 | 34 | R 140.00 |
| 35 to 44 | 35 | 44 | R 157.00 |
| 45 to 54 | 45 | 54 | R 184.00 |
| 55 to 59 | 55 | 59 | R 420.00 |
| 60 to 64 | 60 | 64 | R 580.00 |
| 65 and over | 65 | 120 | R 730.00 |
Premiums are charged per insured person per month, based on the age band into which that person falls.
The policyholder is the sole contracting party and is liable for the total premium payable on the policy.
Every rand limit and claim frequency applies per insured person per year unless the benefit states otherwise. A year means the Prescribed Period, 1 January to 31 December.
✦ 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).
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?
Because Nexus is rated per life, the premium only exists once you add up the actual people on the policy. Add each member below to see the total.
Speak to your broker or contact us directly for a quote on the Nexus 1 option, the entry point to new-generation gap cover from X Underwriting Managers.