Advanced Gap Cover, Rated Per Policy
Broad in-hospital and emergency protection with a full cancer suite, on a single premium for the policy. Eleven benefits covering the shortfalls that create the largest and most frequent bills.
Advanced gap cover for people who want the shortfalls that matter most taken care of, on one straightforward premium for the whole policy.
Vertex 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 account, the option extends to emergency room treatment and a full suite of cancer benefits, including co-payments, top-up cover once a scheme limit is reached, and a R25 000 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, and an accidental death benefit is paid to the nominated beneficiary.
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-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 | Up to R15 000 per claim, 3 claims per policy 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. Subject to OAL. |
| Hospital Account Shortfalls | R2 500 per claim, 4 claims per policy per annum. Covers consumables and take-home medication scripted and dispensed by the hospital pharmacy on the day of discharge. Includes one private room upgrade of R2 500 per policy per annum. Subject to OAL. |
| Emergency | |
| Emergency Room | R20 000 per policy 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. |
| 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 Diagnosis of Cancer ✦ | 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. |
| Support Benefits | |
| 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 OAL. |
| Accidental Death ✦ | R8 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. |
These benefits are available on other options in the range.
One premium for the policy, with the rating age determined by the eldest insured person.
| Cover | 18 to 54 | 55 to 64 | 65 and over |
|---|---|---|---|
| Individual | R 450.00 | R 550.00 | R 950.00 |
| Family | R 560.00 | R 700.00 | R 1 150.00 |
| Additional child | R 40.00 | N/A | N/A |
Family cover is the principal member plus one adult dependant and up to three child dependants. Additional child dependants may be added at R40 per month. Further adults cannot be added to the policy.
Child dependants are covered up to age 21, or age 27 for full-time students.
The rating age, and therefore the age category, is determined by the eldest insured person.
All benefits are subject to the Overall Annual Limit of R223 000 per insured person per annum from 1 April 2026, except those marked ✦.
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.
Speak to your broker or contact us directly for a quote on the Vertex option.