This is not a Medical Scheme and the cover is not the same as that of a Medical Scheme.
This Policy is not a substitute for Medical Scheme membership.
What is Gap Cover?
Gap Cover is a short term insurance product that helps you cover certain cost shortfalls that your medical aid does not cover. These medical shortfalls occur when your selected doctor or medical specialist charges rates that are more than what your medical aid will pay for. These shortfalls vary according to the fees charged by a medical specialist and the nature of the procedure required.
Old Mutual Gap Cover provides you with peace of mind and financial cover for in-hospital and defined out-of-hospital medical expense shortfalls. It also allows you to be able to choose the best medical care for you and your family.
Why Gap Cover is essential:
Gap Cover is essential due to the high cost of specialist treatments and above-inflation increases, meaning that more people are at risk of being left behind and excluded from the quality medical care they need and deserve.
Many medical disciplines are increasing their charges at a rate much higher than that of inflation, some up to 500% of medical aid rates. Patients and their families are required to meet the cost shortfalls that exist between what their medical aid covers and the actual charge of the specialist.
Old Mutual Gap Cover Benefits:
- Tariff Shortfalls
- Consumables
- Oncology Co-Payments & Sub-Limits
- Step Down Facility
- Dental Reconstruction Benefit
- Accidental Casualty
- Child Casualty Illness
- Casualty Emergency
- Innovative Oncology Medicines
- Accidental Death & Disability Benefit
- Oncology-First Time Diagnosis
- Medical Aid Contribution Waiver
- Old Mutual Gap Premium Waiver
Brochures:
2026 Brochure
Resources:
Understanding Your Gap Cover Policy
Gap Claim Journey
Frequently Asked Questions
General
What is Gap Cover?
Gap Cover is a non-life insurance product that helps you cover certain tariff shortfalls between what your medical provider charges and what your medical aid pays.
How do these shortfalls occur?
They occur when your selected doctor or medical specialist charges more than what your medical aid pays for a procedure or specific code. This is called a ‘tariff’ shortfall.
Do all specialists charge more than the medical aid tariff?
A lot of them do and the charges vary from 1.5 times above what the medical scheme covers up to as much as 5 times more than the medical aid tariff.
How much is a tariff shortfall?
Tariff shortfalls vary according to the fees charged by your medical specialist and also the severity of the procedure. Typically, the shortfalls on minor procedures are several thousand rands and can be anywhere between twenty and forty thousand rands on large procedures.
Tariff Shortfall – The difference between what the medical practitioner or facility charges and what your medical scheme pays out as their set rate for the specific treatment/ procedure.
Co-payment – A co-payment is a fixed amount that your medical aid scheme requires you to pay from your own pocket for a specific medical treatment or procedure.
Can shortfalls occur in any other way?
Yes, they can also occur if your medical aid imposes co-payments or deductibles on certain procedures, e.g. MRI/CT scans or diagnostic scopes while in hospital.
How much is a co-payment or a deductible?
It all depends on your medical aid plan and on the type of procedure, but they range from around R2,000 up to as much as R15 000 per case.
How often does Gap Cover pay claims?
Gap Cover claims are processed daily and benefit payments payable to dependants are also made daily. Claims take 7 – 14 working days to finalise once all required documents are received.
How do I claim from my Gap Cover?
You can complete our online claim form here.
What supporting documents are required in order to claim from my Gap Cover?
A copy of the doctor’s invoice, copy of the hospital account and a copy of your medical aid scheme statement showing the shortfall.
Will all my shortfalls be covered by Gap Cover?
The policy does contain some exclusions, please refer to your policy document for the detailed list.
Are my dependants covered?
Dependants can be included in your policy if you apply for their cover and they meet the eligibility criteria as noted in the policy.
If I would like to cancel, what is the notice period?
A minimum of 31 days’ notice is required in order to cancel your policy.
Will I have any waiting periods?
The waiting periods are as follows:
- Three (3)-month general waiting period
- A twelve (12)-month condition-specific waiting period
If proof of previous cover is provided, the waiting periods will be reviewed and removed.
Better Rewards
Better Rewards is the Dis-Chem rewards programme available to Kaelo policyholders as part of their Lifestyle Benefits which may be selected at an additional fee.
What are the Better Rewards benefits?
The Better Rewards programme gives Policyholders access to a 20% discount on a basket of healthy and essential products purchased from Dis-Chem stores and online. If a Better Rewards product is already on promotion or discount, the Policyholder will receive both discounts. There is also an opportunity to boost the discount with a 5% Pharmacy Boost and a 5% Capitec Boost. T&Cs Apply.
How do I redeem my Better Rewards?
To redeem your Better Rewards discount, swipe or scan your physical or digital Dis-Chem Better Rewards card at the tills when paying for your purchases in-store or on-line when logged into your Dis-Chem online profile.
How do I qualify for Better Rewards?
You need to be a Kaelo policyholder with Lifestyle Benefits and a Dis-Chem Better Rewards member. The 20% discount is automatically applied at the tills when scanning your Dis-Chem Better Rewards card or when making a purchase from the Dis-Chem Online store.
Are there any waiting periods for Better Rewards?
No, Better Rewards are activated on the inception date of your Kaelo Policy and remain active as long as your Policy is in good standing.
Can I redeem Better Rewards with my policyholder card?
No, Better Rewards cannot be accessed by presenting the Kaelo Health digital card, this card is only used for Prime Cure Providers, Dispensary or Clinic services to access Policy Benefits (medication, consultations or healthcare services). You need to use your Better Rewards card.
Can my dependants access Better Rewards?
No, the Better Rewards benefit is only available to the main Policyholder.
Do Policyholders have to pay an additional cost for Better Rewards?
Better Rewards is part of Lifestyle Benefits which may be selected at an additional fee.
This is not a Medical Scheme and the cover is not the same as that of a Medical Scheme.
This Policy is not a substitute for Medical Scheme membership.
Kaelo Risk (Pty) Ltd is an authorised financial services provider (FSP 36931).
This product is underwritten by GENRIC Insurance Company Limited (FSP: 43638). GENRIC is an authorised Financial Services Provider and licensed non-life Insurer.