Enhanced Gap Cover, Priced Per Life
A new generation of gap cover. Broader protection that adds robotic surgery, appliances, specialist and primary care consultations and breast reconstruction to the core suite, priced per life so that every member pays the lowest premium their own age allows.
Enhanced gap cover for people who want protection well beyond the hospital account, at a premium that reflects their own age rather than a blended family rate.
Nexus 2 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, and 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 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 codes 0018 and 0019 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, 1 claim per insured person 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. Limited to R40 000 per insured person per annum in aggregate. Subject to OAL. |
| Hospital Account Shortfalls | R2 000 per claim, 2 claims per insured person per annum, covering consumables and take-home medication scripted and dispensed by the hospital pharmacy on the day of discharge. Plus 1 private room upgrade per insured person per annum, up to R2 000 per claim. Subject to OAL. |
| Appliance Shortfall | R5 000 per insured person 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 | R5 000 per insured person 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 000 per consultation, 2 claims per insured person per annum, where the medical scheme has paid a portion of the consultation fee. Excludes tests, scans and charges unrelated to the consultation, and any provider covered under Primary Care. Subject to OAL. |
| Primary Care Consultations | R500 per consultation, 2 claims per insured person per annum in total 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, 1 claim per insured person 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 | R5 000 per insured person 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 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 ✦ | 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 for all remaining insured persons are waived for six months. Premium adjustments within the period adjust the credit balance accordingly. 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 500 per month for the principal member, R2 000 for each adult dependant and R1 000 for each child dependant, limited to R7 500 per month for the policy as a whole. Membership must have been active for six months prior to the event and remain active, with the Certificate of Membership presented monthly. Payable from the month after the event. Not subject to OAL. |
| Accidental Death ✦ | R15 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. |
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 50.00 |
| 22 to 24 | 22 | 24 | R 130.00 |
| 25 to 34 | 25 | 34 | R 161.00 |
| 35 to 44 | 35 | 44 | R 181.00 |
| 45 to 54 | 45 | 54 | R 212.00 |
| 55 to 59 | 55 | 59 | R 483.00 |
| 60 to 64 | 60 | 64 | R 667.00 |
| 65 and over | 65 | 120 | R 840.00 |
Premiums are charged per insured person per month, based on the age band into which that person falls. No distinction is made between the principal member and an adult dependant.
The policyholder remains the sole contracting party under the policy and is liable for the total premium payable.
Every rand limit and claim frequency applies per insured person per annum unless the benefit states otherwise. In this schedule, per annum 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 annum from 1 April 2026.
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.
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 2 option, the broader tier of new-generation gap cover from X Underwriting Managers.