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 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 | R45 000 per policy per year, up to 3 claims of R15 000 each, 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 | R10 000 per policy per year, up to 4 claims of R2 500 each. Covers 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 500 per policy per year. Subject to OAL. |
| Emergency | |
| Emergency Room | R20 000 per policy per year across accident, trauma and illness. Accidents up to R2 500 per claim, at any time. Illness is covered after hours only: up to R2 500 per claim for beneficiaries aged 8 and older, or R5 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. |
| 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.
Everything needed to quote and compare Vertex. 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.
One premium covers the policy. The eldest insured person sets the age band.
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.
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.
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 year (1 January to 31 December), 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.
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?
Speak to your broker or contact us directly for a quote on the Vertex option.