Are day-to-day General Practitioner (GP) consultations covered?

No, day-to-day services such as GP, specialist, optometry and dentist visits are not covered. These include specialist consultations not billed as part of the hospital or out-of-hospital procedure such as pre- and post-procedure consultations.

Do I need to be a member of a medical scheme to qualify for Liberty Gap Cover?

Yes, you can only enjoy cover under this policy for as long as you remain a principal member or dependant of a South African registered medical scheme.

Do I need to provide details of dependants on my medical scheme and changes to my medical scheme dependants?

No, at the time of the claim, confirmation will be required to prove that claimants were dependants of your medical scheme.

Does the Liberty Gap Cover Policy cover physiotherapy sessions?

Liberty Gap Cover provides benefits for the shortfall in excess of the medical scheme tariff if the physiotherapy treatment was in-hospital and was covered by your medical scheme. Shortfalls for out-of-hospital physiotherapy sessions are not covered by the policy as these sessions are not a covered out-patient procedure and day to day treatment is a policy exclusion. Clients are responsible to pay for day to day treatment from their medical savings.

Does the policy cover more than one eligible spouse?

If you have more than one eligible spouse/partner, then you must nominate the spouse/partner that will be covered. If you do not nominate a spouse/partner, then neither of the spouses/partners will be covered.

Does the policy cover orthognathic surgeries?

The shortfall on orthognathic surgery (surgery to correct conditions of the jaw and face) will be covered, provided:
  1. The surgery was not treated as an elective/cosmetic procedure by the medical scheme and was covered and paid by the medical scheme from the Major Medical Benefit (MMB).
  2. The in-hospital treatment is not subject to the 12-month pre-existing condition exclusions within the first 12 months of cover.
Any consumables, medicines, materials, appliances, equipment, dental implants, are not covered by the Gap policy as this is not a doctor’s service charge for performing the procedure.

Does this policy have a surrender value?

There is no savings or endowment portion to the policy and therefore no surrender value to the policy.

How do I submit a claim?

This can be done by contacting Zestlife, who will advise you what documents to complete when submitting a claim. Please remember to notify Zestlife within 6 months of the medical treatment taking place and to submit all claim-related documents within 12 months of treatment.

How long does it take to pay a claim?

Approximately 15 working days from receipt of a completed claim form and all required documentation.

I have been diagnosed with stage 2 qualifying cancer* for the first time, but have decided not to go for further treatment and therefore do not need to register on my medical scheme’s oncology treatment programme. Do I still qualify for the R25 000 lump sum cancer benefit?

No, to qualify for the benefit you must be diagnosed with stage 2 qualifying cancer for the first time AND you must be registered on your medical scheme’s oncology programme. *Excludes skin cancer.

I have been diagnosed with stage 2 qualifying cancer* for the first time. The cancer has been surgically removed, no further treatment is required and therefore I do not need to register on my medical scheme’s oncology treatment programme. Do I still qualify for the R25 000 lump sum cancer benefit?

No, to qualify for the benefit you must be diagnosed with stage 2 qualifying cancer for the first time AND you must be registered on your medical scheme’s oncology programme. *Excludes skin cancer.

I have existing Gap Cover. If I cancel it to take out your policy, how will this affect me?

Replacing your existing Gap Cover with Liberty Gap Cover will not negatively impact you in any way. The pre-existing condition waiting period will only be applied to the unexpired part of the pre-existing condition waiting period from the previous policy. The pre-existing condition waiting period will, however, apply for the full period of 12 months for any benefit not provided under the previous policy.

I have had Gap Cover with another provider for 5 years and need an operation that requires an upfront co-payment. If I take out Liberty Gap Cover, will you cover the co-payment?

If your previous policy did not provide co-payment cover and this is a pre-existing condition, then the full 12-month pre-existing condition waiting period will be applied to the co-payment benefit and no claim for this will be paid.

Is Liberty Gap Cover only valid on a specific medical scheme?

No, Liberty Gap Cover can be taken out to cover individuals on any South African registered medical scheme.

Is my partner covered under my Liberty Gap Cover policy?

Yes, but only if he/she is covered on your medical scheme. If your partner to whom you are not legally married, has his/her own medical scheme, then your partner will have to take out their own Gap Cover policy.

Is there a policy fee attached to this policy?

There is absolutely no additional policy fee, the costs incurred for administration are covered in your premium.

Must details of the medical scheme dependants be provided when taking out cover? And, must the policyholder notify the insurer of any dependants that should be removed from or added to the list of dependants insured under the policy?

No, at the time of the claim, confirmation will be required to prove that claimants were dependants of your medical scheme and therefore insured under the policy. The only exception is if you are on the premium applicable to single persons younger than 55 years and you add a dependant to your medical scheme. In this case, you need to notify us, otherwise your dependants on your medical scheme, or a qualifying spouse on his/her own medical scheme will not be covered.

My 3 month old son is going for a circumcision and the doctor does not charge medical scheme rates. Will the Liberty Gap Cover Policy cover the shortfall?

Routine and ritual circumcision is an elective procedure and the shortfalls are therefore not covered.

My child had a high fever and was vomiting so I rushed him to the hospital emergency unit as it was after hours. Will the Liberty Gap Cover Policy cover this and reimburse me for the fees that I had to pay?

Unfortunately not, as the emergency room/casualty benefit is only payable if the treatment was accident related and not if it was due to illness.

My medical scheme cover started last month. Can I backdate my Liberty Gap Cover to coincide with my medical scheme cover start date?

This is a risk policy and cover can only start from a future date after application, as the policy is designed to cover you for future unforeseen events.

Should I wish to cancel the policy, how would I go about doing so?

The policy may be cancelled at any time by giving one calendar month’s written notice.

To whom is the benefit paid?

The benefit is paid directly to the policyholder, who is then responsible for settling the accounts with the doctors and specialists. The claim benefit cannot be paid into a business bank account or into a third party’s bank account.

What cover exclusions exist for Liberty Gap Cover?

The list of exclusions include standard insurance exclusions such as sickness or injury caused from nuclear weapons or material, injury from an accident while over the legal alcohol limit, active participation in war, police duty, civil commotion. Then there are a number of specific exclusions such as cosmetic surgery, treatment for obesity, cancer treatment received outside of South Africa and any event not covered by your medical scheme. It is, however, worth studying the full list of exclusions that appears in the Liberty Gap Cover policy document.

What documentation is required to replace your existing Gap policy with Liberty Gap Cover?

We require the following documents to be submitted with the completed Liberty Gap Cover application form:
  • A copy of your current Gap Cover policy contract and schedule confirming the policy commencement date and current benefits provided by the policy.
  • Confirmation of the policy cancellation and cover cease effective date.
  • Medical scheme membership confirmation, confirming all those who were covered under the policy contract unless the lives insured are stated in the policy schedule.
  • Replacement policy advice record.

What documents do I need to submit with a Liberty Gap Cover claim?

You need to submit the completed claim form along with copies of your hospital account, doctors’ accounts and detailed medical scheme statement reflecting payment to the hospital and doctors. When you are claiming for reimbursement of a co-payment, a copy of the medical scheme pre-authorisation letter and proof of co-payment paid is also required.

What does Liberty Universal Gap cover?

A. Medical Expense Shortfall Cover

The policy covers doctor and specialist treatment charge shortfalls that are not covered in full by your medical scheme. Cover is also provided for medical scheme co-payments levied. Together, these are known as the Medical Expense Shortfall Cover.

Health insurance Regulations place a limit of R150 000 for each 12-month period for the Medical Expense Shortfall benefits payable for each person insured under the policy. This limit applies to all the benefits listed under the Medical Expense Shortfall Cover.
(This limit will be increased in April 2018 in line with the regulation announcement.)
  1. In-hospital Cover: The policy covers any shortfall that exists between in-hospital doctor(s)’ charges and the amount paid by your medical scheme. This shortfall is calculated as the difference between the medical practitioner’s charges (limited to five times the medical scheme tariff), less the higher of the amount payable by your medical scheme or the medical scheme tariff.
  1. Out-of-hospital Cover: The policy covers the shortfall between doctors’ out-patient treatment charges and the amount paid by your medical scheme. This covers ±50 out-patient procedures and treatments. This shortfall is calculated as the difference between the medical practitioner’s charges (limited to five times the medical scheme tariff), less the higher of the amount payable by your medical scheme or one times the medical scheme tariff.
  1. Internal Prosthesis and Artificial Joint Cover: Shortfall cover of up to R30 000 per policy per calendar year for internal prostheses such as artificial joints. This benefit is payable after the exhaustion of the medical scheme specified limit or threshold has been exceeded. Cover for intraocular lenses are excluded.
  1. Co-payments Cover: Full cover for upfront co-payments that are charged by medical schemes for hospital admissions, scans and certain surgical procedures. Please note that Penalty co-payments that are imposed by medical schemes for not following the rules of the scheme are not covered. Examples of these penalties are amounts due as a result of not obtaining pre-authorisation from the medical scheme for a procedure or consulting a specialist without first obtaining a referral from a general practitioner (GP).
  1. Non-DSP Co-payment Cover: Up to R8 600 each year for each policy (one claim per year) is provided to cover the co-payment when using a hospital outside of the medical scheme’s approved Designated Service Provider (DSP) network.
  1. Enhanced Cancer Cover: In addition to the Gap and Co-payment Gap benefits that cover the shortfalls on cancer treatment, additional cancer-specific cover is provided.
6.1 Cover for the co-payment as levied by medical schemes when the member’s total annual cancer treatment limit is exceeded. This cover is subject to a maximum co-payment of 20%.

6.2 Up to R20 000 cover is provided for cosmetic breast reconstruction, for surgical costs that are not covered by the medical scheme for breast reconstruction of a non-affected breast in the event of a single mastectomy resulting from cancer.
  1. In-hospital Dentistry Expense Shortfall Cover: This benefit covers in-hospital dental treatment as covered by the policyholder’s medical scheme and is calculated as follows: (combined dentist and specialist charges up to but not exceeding 5 times the medical scheme tariff) minus (the greater of either the medical scheme’s contribution towards these charges or the medical scheme’s stipulated tariff amount for these charges).
  1. Emergency Room Cover: Accident-related charges incurred for in-hospital casualty ward treatment are covered. This benefit covers the facility fee, consultations, medications, radiology and pathology associated during admission to a registered hospital’s casualty facility due to an accident. Where a full in-hospital admission follows casualty ward treatment, only the shortfall amount not covered by the medical scheme will be covered. This benefit will pay up to R10 000 per policy per calendar year and is payable irrespective of whether your medical scheme covered the costs. The shortfall is calculated as the Emergency Room charges minus the amount paid by your medical scheme.
B. Health Insurance Cover

The cover items listed below are not subject to the overall regulated Medical Expense Shortfall limit per individual insured, per year.
  1. Lump Sum Cancer Cover: R25 000 is payable in the event of first-time stage 2, 3 or 4 cancer diagnosis. Payment of this benefit is also subject to the insured’s registration on the medical scheme’s oncology treatment programme. This is, however, a fixed benefit payment and is not reliant on verification of actual treatment costs. This cover excludes skin cancer and applies to cancer diagnosed after the commencement of cover and after completion of the 12-month waiting period.
  1. Accidental Dentistry Cover: Accidental tooth fracture cover, for tooth fractures caused from an external blow to the mouth. This is provided per individual per calendar year. This cover is payable at a rate of R2 250 per tooth, irrespective of cover provided by the medical scheme. This benefit will pay up to R15 750 per policy per calendar year.
  1. Accidental Death and Permanent Disability Cover: A R50 000 lump sum benefit is paid in the event of accidental death or accidental permanent disability. This cover ceases at age 65 in respect of accidental permanent disability.
  1. Trauma Counselling Cover: Trauma counselling cover of R750 per session, subject to an annual policy limit of R25 000.
  1. Medical Scheme and Gap Policy Premium Cover: This benefit covers the actual medical scheme and Liberty Gap Cover premium amounts in the event of the policyholder’s death or permanent disability. Cover is subject to a maximum payment of R6 500 per month, for three consecutive months. Cover ceases at age 65.

What does the Liberty Essential Gap Policy cover?

A. Medical Expense Shortfall cover

The policy covers doctor and specialist treatment charge shortfalls that are not covered in full by your medical scheme. Cover is also provided for medical scheme co-payments that are levied. Together, these are known as the Medical Expense Shortfall Cover.

Health insurance regulations place a limit of R150 000 for each 12-month period for the Medical Expense Shortfall benefits payable for each person insured under the policy. This limit applies to all the benefits listed as Medical Expense Shortfall Cover.
(This limit will be increased in April 2018 in line with the regulation announcement.)
  1. In-hospital Cover: The policy covers any shortfall that may exist between doctors’ in-hospital charges and the amount paid by your medical scheme. This shortfall is calculated as the (combined doctors’ and specialists’ charges) minus (the greater of either the medical scheme’s contribution towards these charges or the medical scheme’s stipulated tariff amount for these charges). This benefit amount is limited to shortfall amounts that are less than or equal to double the medical scheme’s contribution to these charges.
  1. Out-of-hospital Cover: The policy covers the shortfall between doctors’ and specialists’ out-patient treatment charges and the amount paid by your medical scheme. This covers ±50 out-patient procedures and treatments. This shortfall is calculated as (combined doctors’ and specialists’ charges for ±50 out-of-hospital treatments listed in the policy document) minus (the greater of either the medical scheme’s contribution towards these charges or the medical scheme’s stipulated tariff amount for these charges). This benefit includes cover for CT, PET and MRI scans. The benefit is limited to a shortfall amount less than or equal to double the medical scheme’s contribution to these out-of-hospital charges.
  1. Co-payments Cover: Full cover for upfront co-payments that medical schemes charge for hospital admissions, scans and certain surgical procedures. Please note that Penalty co-payments that are imposed by medical schemes for not following the rules of the scheme are not covered. Examples of these penalties are amounts due as a result of not obtaining pre-authorisation from the medical scheme for a procedure or consulting a specialist without first obtaining a referral from a general practitioner (GP).
  1. Emergency Room Cover: Accident-related charges incurred for in-hospital casualty ward treatment are covered. This benefit covers the facility fee, consultations, medications, radiology and pathology associated during admission to a registered hospital’s casualty facility due to an accident. Where a full in-hospital admission follows casualty ward treatment, only the shortfall amount not covered by the medical scheme will be covered. This benefit will pay up to R10 000 per policy per calendar year and is payable irrespective of whether your medical scheme covered the costs. The shortfall is calculated as the Emergency Room charges minus the amount paid by your medical scheme.
B. Health Insurance Cover

The cover items listed below are not subject to the overall regulated Medical Expense Shortfall limit per individual insured, per year.
  1. Accidental Death and Permanent Disability Cover: A R50 000 lump sum benefit is paid in the event of accidental death or accidental permanent disability. This cover ceases at age 65 in respect of accidental permanent disability.
  1. Trauma Counselling Cover: Trauma counselling cover of R750 per session, subject to an annual policy limit of R25 000.

What happens if, as the policyholder, I pass away before my spouse?

Your spouse can continue the cover should they elect to do so, provided they inform Zestlife, the policy administrator, in writing within 90 days.

What is an extended adult dependant?

An extended adult dependant is either a parent or sibling of the policyholder who is registered on their medical scheme as an extended adult dependant.

What is the oldest age at which an individual can apply for cover?

There is no maximum entry age.

What out-of-hospital procedures are covered?

Although Liberty Gap Cover has been primarily designed to cover shortfalls and co-payments arising from in-hospital procedures, benefits are also payable in the event of shortfalls and/or co-payments arising from certain out-patient procedures. The procedures that are covered on an out-patient basis include:
• Arthroscopy • Bronchoscopy
• Bunionectomy • Cataract removal
• Carpal Tunnel Release • Chemotherapy or radiotherapy for the treatment of cancer
• Cervical laser ablation • Closure of colostomy
• Childbirth in a non-hospital setting • Coronary angiogram
• Colonoscopy or sigmoidoscopy • CT Scan – Computer Axial Tomography
• Coronary angioplasty • Dilatation and curettage
• Cystoscopy • Endoscopy
• Direct laryngscopy • Gastroscopy
• Ganglion surgery • Hysteroscopy
• Grommets • Incision and drainage of Bartholin’s cyst
• Hernia Repairs, limited to: • Ischio-rectal abscess drainage
- Inguinal Hernia • Kidney dialysis
- Femoral Hernia • Marsupilisation of Bartholin’s cyst
- Umbilical Hernia • MRI – Magnetic Resonance Imaging
- Epigastric Hernia • Pterygium removal
- Spigelian Hernia • Tubal ligation
• Myringotomy • Oesophagoscopy
• Needle biopsy of the liver • Orchidopexy
• Surgical biopsy of breast lump • Surgical Hemorrhoidectomy (excluding sclerotherapy or band ligation)
• Lymph node biopsy • Prostate biopsy
• PET – Positron Emission Tomogrophy • Tonsillectomy
• Sinus surgery, limited to
- Frontal sinus
- Functional endoscopic sinus
- Bilateral function endoscopic sinus
•Trabeculectomy

What waiting periods apply to Liberty Gap Cover?

There is no 3-month general waiting period, and no general or condition-specific waiting periods apply. However, no benefits can be claimed for a period of 12 months from the start date of cover in respect of medical conditions, for which in the 12 months before the start date of the cover, medical advice, diagnosis, care or treatment was received or would reasonably have been recommended. Pregnancy before the start date of cover will be regarded as a preexisting condition, and any pregnancy and birth-related claims will be excluded for 12 months from the start date of the cover. If prior to the start date of Liberty Gap Cover, a policyholder had cover under another Medical Expense Shortfall Policy, then the pre-existing condition waiting period will only be applied to the unexpired part of the pre-existing condition waiting period from the previous policy. The pre-existing condition waiting period will, however, apply for the full period of 12 months for any benefit not provided under the previous Medical Expense Shortfall Policy.

When does the policy terminate?

There is no specific age limit that gives rise to this policy terminating. However, if the policyholder allows the policy to lapse or when the policyholder cancels the policy, the policy will terminate. Please also be aware, that cover for certain benefits cease at age 65.

When will I receive my policy documents?

Your policy documents will be sent to you within 1 week of taking out Liberty Gap Cover.

When will premium payments commence?

The first premium will be debited on a day of your choice as per the selection made in your application form.

Which Insurer underwrites the Liberty Gap Cover policies?

Your Liberty Gap Cover policy is underwritten by Guardrisk Insurance Company Limited (FSP number 76) (collectively referred to as “Guardrisk”).

Which internal prostheses will be covered by the policy?

An internal prosthesis is a device that is placed inside a person’s body during a procedure to permanently replace a body part. In other words, a body part is removed and permanently replaced with a prosthesis during surgery. Examples include joint replacements and spinal fusions. These type of prostheses will be covered. Intraocular lenses and devices that are placed inside a body to help a functioning body part (for example, a pacemaker, stents etc.) are not covered.

Who is covered?

Cover is available to members of all South African registered medical schemes. Cover applies to the main medical scheme member and all family members listed as medical scheme dependents. The policyholder’s legally married spouse and child dependents will also qualify for cover even if they are registered on the spouse’s own medical scheme. Single medical scheme members under the age of 55, as the only life insured by the policy, qualify for a lower monthly premium. These members on the lower rate need to notify Zestlife if their circumstances change meaning that they have other dependants who should also be covered by their Gap policy. These dependants are not covered until such time that Zestlife has been notified. An over age 65 premium applies if the main medical scheme member or any of their dependents are 65 years or older. There is no maximum entry age and cover continues without a maximum expiry age.

Why can we not automatically adjust the policy premium for a member under the age of 55?

We do not have access to a client’s medical scheme membership information and are therefore not aware of any changes to a client’s dependant details. It remains the client’s responsibility to notify us if they are the only person covered on the medical scheme and they qualify for the reduced premium.

Will Gap cover the costs if my wife has a home birth?

This out-of hospital procedure is covered, so the shortfall on the charges in excess of the medical scheme tariff rate for the midwife/ nurse will be covered by Liberty Gap Cover. This is provided that the claim is not subject to the 12-month pre-existing condition exclusion applicable to the first 12 months of cover.

Will I be required to go for a medical examination to qualify for cover?

There are no medicals required when applying for Liberty Gap Cover and cover is immediate.

Will my premium increase each year?

Yes, as with most insurance policies, the premium is likely to increase each year. The premium amount will be reviewed every year and policyholders will be notified in advance of any increases which will be made effective on 1 January of each year. The policy terms and conditions are also reviewed annually and changes are effective from 1 January every year.

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