Sirago Gap Cover Product Brochure 2023

1

Sirago Gap Cover Solutions 2023

TABLE OF 03
04
CONTENTS 05
06-07
Introduction 08
Contact details 09
Who is covered 10-11
Application of Waiting Periods 12-13
Claims examples 14-16
How to claim 17-19
Explanation of the various Benefit Categories 20-21
Easy to understand Gap Option comparison 22-23
Ultimate Gap 24
Plus Gap 25
Gap Assist 26-27
Gap Lite 28-29
Gap Only 30-31
Corporate Solutions
Exact Cover
Exact with Gap & Co-pay
Important Terms & Conditions

INTRODUCTION

Sirago Underwriting Managers WHY CHOOSE
(Pty) Ltd is an Authorised Financial SIRAGO GAP COVER?
Services Provider (FSP: 4710)
underwritten by GENRIC Insurance • Personalised customer service
Company Limited (FSP: 43638). • Variety of options
GENRIC is an Authorised Financial • Cover for in-and-out-of-hospital
Services Provider and licensed non- • Shortfall cover for day-to-day
life insurer.
specialists, GPs, dentists, and
Sirago offers a variety of Gap Cover alternative therapists
solutions tailored for the unique • Emergency room cover for
requirements of the South African accident, trauma, and illness
healthcare market. Our philosophy of • No maximum entry age and
continuous improvement means that benefits do not cease at 65, unless
you are always guaranteed individual specif ied
attention and superior products, • Cover for you and your family,
which will meet your needs and either on a single medical scheme
exceed your expectations. or on two medical schemes
• We pride ourselves on effective
Our competitive and affordable turnaround times, so as not to
products are unparalleled in the compromise policyholders
marketplace and are the ideal • Claims are paid to the policyholder,
complement to your overall unless arrangements have been
healthcare portfolio. With a range of made to settle directly with the
Gap Cover options, Sirago provides service provider
comprehensive effective cover to suit • Daily claim runs
every individual.

WHAT IS GAP COVER?

Gap Cover is the invaluable safety net that covers the shortfall between what
medical schemes pay and what specialist doctors charge.

Without this, policyholders may find themselves paying for unexpected costs
f rom their own pockets.

Disclaimer:

This is not a substitute for a medical scheme membership and the cover is not the same as that of a
medical scheme. This is a Short-term Insurance Accident and Health policy in terms of the
Short-term Insurance Act 53 of 1998. Terms and conditions apply.

DID YOU KNOW? 3

You are under no obligation to divulge
any information about your personal insurance

portfolio to any provider or outside party,
even if the hospital or specialist requests it.

Sirago Underwriting Managers (Pty) Ltd is an Authorised Financial Services Provider (FSP: 4710), underwritten by
GENRIC Insurance Company Limited (FSP 43638), an Authorised Financial Services Provider and licensed non-life Insurer.

Sirago Gap Cover Solutions 2023

CONTACT DETAILS

// Talk to one of our customer services consultants Centurion
Irene Link Precinct,
on email, WhatsApp, or via telephone: +27 10 599 1163. 7 Impala Avenue,
Centurion, 0157
For new applications or to follow up on submitted Florida
applications, please contact your broker, or send an email Floor 2, Fauchard Clinic &
to [email protected] Centre, Cnr. Jan Smuts
& Jan Hofmeyer Ave,
Client queries or policy updates: Florida Park, Roodepoort
[email protected] JHB, 1709
Cape Town
To make changes to existing policies: Edward 3, 101A
[email protected] 70 Edward Rd,
Upper Oakdale, Bellville,
For new claims or follow-ups on claims: Cape Town, 7530
[email protected] Mon-Fri
08:00 - 17:00
For new groups or follow-ups on groups:
[email protected] CHAT TO US

For any payment or commission-related queries: BROKER PORTAL
[email protected]

Broker queries & general policy servicing:
[email protected]

Disclaimer:

This policy does not discriminate or refuse membership based on race, age, gender, marital
status, ethical or social origin, sexual orientation, pregnancy, disability, state of health,
geographical location, or any other means. We may however charge a different premium
dependent on your age at the time of inception, or apply waiting periods if applicable.

4

WHO IS COVERED?

We cover policyholders and benef iciaries of all ages. The benchmark for premium determination
is based on whether you join as an individual or as a family, and the prospective policyholder’s
age at the inception of the policy according to the following two age bands:
• 64 years and younger, and
• 65 years or older.

We will cover you and all the dependants registered on your medical scheme on one policy.

If you belong to 2 different medical schemes, or medical scheme options, we will cover two adults
(i.e. the policyholder and one other adult dependant, if applicable) and all child dependants on
one policy.

A child is considered to be a child dependant up to the age of 21, however cover can be extended
to the age of 27 for full-time students. Documented proof of full-time study enrolment is
required to verify a dependant over the age of 21, or by providing the Certif icate of Membership
(COM) from your medical scheme confirming that the dependant is still on the same medical
scheme.

GENRIC Insurance Company Limited (FSP 43638) 5

Sirago Gap Cover Solutions 2023

APPLICATION OF

WAITING PERIODS

A “WAITING PERIOD” IS A DEFINED PERIOD OF TIME IN WHICH A POLICYHOLDER
MAY NOT CLAIM ANY, OR MAY ONLY CLAIM CERTAIN POLICY BENEFITS.

GENERAL WAITING PERIODS

• A 3-month general waiting period is applied to newly incepted policies and when
dependants are added to a current policy, except in the event of an emergency.

• A 10-month waiting period is applied to pre-existing conditions, diseases, or illnesses.

POLICY SPECIFIC WAITING PERIODS APPLICABLE TO
CERTAIN PROCEDURES

• The following conditions are excluded within the first 6 months of the inception of the
policy:

- Myringotomy and grommets;
- Adenoidectomy;
- Tonsillectomy;
- Hysterectomy (except if malignancy is proven);
- Spinal, back, neck, and joint-related procedures (repairs, scopes, and joint
replacement) except in the case of an accident. This includes treatments related to
any and/ or investigations such as MRI scans, CT scans, and scopes.
• 50% of benefits will be paid on claims from month 7 to 10.
• From month 11, the policy benefits will be fully available, unless there are condition

specific exclusions.

SPECIFIC WAITING PERIODS FOR CERTAIN BENEFIT
CATEGORIES

• A 10-month waiting period is imposed for pregnancy and confinement.
• Accidental Death, Total Permanent Disability, and Premium Waivers are subject to a

3-month waiting period.
• Initial Cancer Diagnosis is subject to a 3-month waiting period.
• A 12-month waiting period is applied on all pre-existing cancer-related treatments.

6 GENRIC Insurance Company Limited (FSP 43638)

TRANSFER OF COVER

• All waiting periods are waived if you have held cover for 12 months or longer with
your current provider.

• If you are currently serving waiting periods with your current provider, the balance is
applicable at Sirago.

• If you are transferring to a higher option, a 3-month general waiting period is
applied on all additional benefits.

SIRAGO COVER UPGRADES

• If the Sirago policyholder has held a policy for 12-consecutive months and wants to
upgrade to a higher option, all additional benefits will be subject to a 3-month waiting
period.

• If the Sirago policyholder has held a policy for less than 12-consecutive months and
wants to upgrade to a higher option, the difference between the balance of the
waiting periods imposed will be applied, and a 3-month waiting period on additional
benef its.

DID YOU KNOW?

Sirago’s clients’ safety and financial security is our number 1 priority!
With us you are in good hands!

Sirago Underwriting Managers (Pty) Ltd is an Authorised Financial Services Provider (FSP: 4710), underwritten by 7
GENRIC Insurance Company Limited (FSP 43638), an Authorised Financial Services Provider and licensed non-life Insurer.

Sirago Gap Cover Solutions 2023

EXAMPLES OF

SIRAGO CLAIMS PAID IN 2022

Knee Specialist Delivery By
Replacement Consultation Caesarean

Anaesthetist Gynaecologist Section
Charged Amount
Charged Amount Gyneacologist
R16 295,31 R1 950 Charged Amount
Scheme Paid
Scheme Paid R27 000
R5 528,30 R448,70 Scheme Paid

Sirago Paid Sirago Paid R3 786,10
R10 767,01 R1 350
Sirago Paid
Surgeon Neurologist R23 213,90
Charged Amount
Charged Amount Malignant
R45 617,08 R2 000 Neoplasm of
Scheme Paid Lymph Nodes
Scheme Paid
R15 381,11 R644,40 Cancer
Charged Amount
Sirago Paid Sirago Paid
R30 235,97 R1 350 R81 556,02
Scheme Paid
Hospital Account Dislocation of
Shortfall Shoulder Joint R17 354,01

Charged Amount Orthopaedic Sirago Paid
R121 510,20 Surgeon R61 264,63

Scheme Paid Charged Amount
R120 591,80 R13 407,53

Sirago Paid Scheme Paid
R918,40 R4 003,40

Sirago Paid
R9 404,13

8 Sirago Underwriting Managers (Pty) Ltd is an Authorised Financial Services Provider (FSP: 4710), underwritten by
GENRIC Insurance Company Limited (FSP 43638), an Authorised Financial Services Provider and licensed non-life Insurer.

HOW TO CLAIM

CEO & Founder STEP 1: Submit your
documents
IMPORTANT TO KNOW
We must receive your claim with all
Make sure to claim in the policyholder’s supporting documentation within 180 days
name (the policyholder is the main after the insured event.
member).
STEP 2: Supporting
documents

• Fully completed and signed Sirago claim
form reflecting policyholder’s details.

• Hospital and all service provider
accounts substantiating your claim.

• Medical scheme statement reflecting
all the payments that your medical
scheme has made towards the service
providers for the treatment dates of the
health event.

• Completed medical reports
substantiating the clinical information or
any other documents that we may need.

• The Pre-authorisation letter reflecting
the scheme imposed co-payment
amount for the event from your
medical scheme for co-payment claims.
Value-Added Benefit claims:
Death certificate or a medical
report from a registered medical
practitioner confirming total
permanent disability.
Histology report for Initial Diagnosis
of Cancer claim.

Completed claims can be sent via email to
[email protected]

SCAN TO CLAIM SCAN ME SCAN ME

+27 10 599 1163 Sirago Website 4Web Broker Portal
for claim assistance
9

Sirago Gap Cover Solutions 2023

EXPLANATION OF THE VARIOUS

BENEFIT CATEGORIES

In-Hospital Benefits Out-Of-Hospital Benefits

GAP COVER PRIMARY CARE BENEFIT
Covers the difference between the medical scheme Primary Care cover is provided for the difference
rate and the rate that service providers charge. between the medical scheme rate and the
provider rate of the consultation fee and
CO-PAYMENTS additional services charged and included with the
Co-payment cover is for the co-payments, excesses, consultation fee.
or deductibles imposed by a medical scheme for
specified procedures, cover for hospital admission DAY-TO-DAY SPECIALIST CONSULTATION FEE
fees, scans, or surgical procedures. Refer to the This benefit covers the difference between the
Cancer Co-payment benef it for claims related to medical scheme rate and the rate charged by
cancer. the specialist for consultation only if your medical
aid pays a portion of the fee from your available
PENALTY FEE CO-PAYMENTS savings.
The amount you have to pay as specified by medical
scheme rules when you choose to use a hospital EMERGENCY ROOM
that is not a designated service provider. This benefit covers an emergency at any registered
emergency/hospital/casualty facility when you
DAY HOSPITAL/CLINIC AND/OR IN-ROOM require immediate medical treatment due to an
SURGICAL PROCEDURES COVER accident, trauma, or illness.
This benefit will cover the shortfall for any day
hospital/clinic and/or in-room procedures including 1. ACCIDENT AND TRAUMA
acute hospitals if a policyholder elects to have the All costs related to the accidental event will be
treatment that would normally be performed on an covered, whether you are liable to pay the costs
in-patient basis, performed as an out-patient, by a related to the emergency event out of your own
registered medical professional. pocket or if your medical scheme pays f rom your
savings.
PRESCRIBED MINIMUM BENEFITS (PMB)
The Prescribed Minimum Benef it Cover is for the 2. ILLNESS
shortfalls resulting from the use of a non-designated All costs related to the emergency illness event will be
service provider for a planned PMB procedure. This covered up to the stated illness benefit, if you are liable
is not applicable in the event of an emergency. to pay the costs related to the emergency event out of
your own pocket, or if paid from your medical scheme
HOSPITAL ACCOUNT SHORTFALL savings. This is applicable to any beneficiary 9 years and
This benefit will cover any charges on the hospital older after normal consultation hours.
account that the medical scheme has not paid. We
may cover consumables, take-home medication or 3. CHILD EMERGENCY ILLNESS
private ward. This benefit is applicable to children 8 years and
under, who need emergency treatment out of normal
SUB-LIMIT ENHANCER consultation hours or treatment that can only be done
The sub-limit enhancer benefit applies when in an emergency room. All costs related to the event
exceeding the benefit limit imposed by your will be covered, whether you are liable to pay the costs
medical scheme for MRI & CT scans, cochlear related to the emergency event out of your own pocket
implants, intraocular lenses, and internal prostheses or if your medical scheme pays from your savings
only, depending on the option. account.

STEP-DOWN PREVENTATIVE CARE
If your medical scheme provides benefits for This benefit will cover the difference between the
rehabilitation as an in-patient in a step-down or rate that the service provider charges and the benefit
sub-acute facility, we will cover ongoing treatments amount on your medical scheme option for any of the
when your medical scheme benefits have been listed procedures or treatments only.
exhausted, after an accident, stroke, or cancer
treatment. The following procedures or treatments are covered
as part of this benefit:Pap smear, cholesterol test,
10 blood glucose test, flu vaccination, childhood
immunisation (Department of Health Formulary)
– up to the age of 12 years, bone-density scans,
prostate-specific antigen tests, mammogram, and
contraceptive implantation only.

APPLIANCE BENEFIT INITIAL CANCER DIAGNOSIS (FIRST DIAGNOSIS)
This benefit covers the difference between the This benefit will pay out a lump sum on the first time you
medical scheme benefit amount and what are ever diagnosed with malignant cancer, excluding
the service provider charges for the following pre-existing cancer and skin cancer.
appliances: hearing aids, wheelchairs, continuous
positive airway pressure (CPAP) machines, SIRA’GO BABY
humidifiers, insulin pumps, glucometers, Sirago will pay out a lump sum for your newborn baby
nebulisers, and Mirena devices. when you send us the birth certificate within 90 days of
birth.
TRAUMA COUNSELLING
This benefit covers trauma counselling with a SIRAGO MEDCARE - FREE MEDICAL SCHEME
registered medical professional after a traumatic ALTERNATIVE DISPUTE RESOLUTION SERVICE
event. (ADR)
With this benefit, the policyholder will get access to
Cancer Benefits MedCare’s free ADR service for all disp uted PMB claims
exceeding R9 000. Policyholders can also access the
CANCER CO-PAYMENT BENEFIT MedCare service for all claims less than R9 000, including
The Cancer Co-payment benefit is applied once all potential medical scheme disputes, at a 60%, 20%,
your medical scheme cancer benefit has been and/or 15% discounted rate depending on the required
reached and a percentage co-payment is imposed. service.
This benefit incorporates co-payments for ongoing
cancer-related treatments and biological drugs. Your broker can also access this service on your behalf
and will subsequently have access to the MedCare
CANCER BOOST BENEFIT website: siragomedcare.co.za.
The Cancer Boost Benefit is applicable to
policyholders whose medical scheme option has
a defined rand limit for cancer treatment and the
rand limit on the medical scheme has been reached.

CANCER BREAST RECONSTRUCTION
The Cancer Breast Reconstruction Benefit provides
additional cover above the medical scheme rate for
breast reconstruction of the affected breast post-
mastectomy. We will also provide a lump sum for
the reconstruction of the unaffected breast, should
the medical scheme not cover this at all. This benefit
is only available within the first 18 months of the
initial mastectomy.

Value-Added Benefits 11

GAP COVER PREMIUM WAIVER
A Premium Waiver benefit may be claimed by the
surviving spouse or adult dependant on the Sirago
policy, in the event of death or total permanent
disability of the Sirago policyholder

MEDICAL SCHEME PREMIUM WAIVER
In the event of death or total permanent disability of
the Sirago policyholder and where all beneficiaries
are linked to a single medical scheme, we will
pay up to the sub-limit for the medical scheme
contributions. This benefit is only payable for the
medical scheme that the policyholder was on if
there is dual medical scheme membership.

ACCIDENTAL DEATH
This benefit will pay out for the accidental death of
policy members.

GENRIC Insurance Company Limited (FSP 43638)

Sirago Gap Cover Solutions 2023

EASY TO UNDERSTAND

GAP OPTIONS COMPARISON

BENEFITS ULTIMATE PLUS

Individual GAP COVER GAP COVER
Family
Age Premium Age Premium Age Premium Age Premium
0-64 0-64
COSTS 0-64 R498 65+ R714 0-64 R395 65+ R615

R566 65+ R821 R452 65+ R701

R191 000 Overall Annual Limit Per Beneficiary Per Annum (from 1 April 2023)

IN-HOSPITAL BENEFITS Gap Cover Additional 500% Up to 500% , max 600%
Robotic surgery R35 000 - R19 000 p/c R18 000 - R6000 p/c
Co-payments and co-payments Subject to OAL
charged as a percentage Subject to OAL R9 500 p/c, 1 claim
Penalty Fee Co-payments R14 000 p/c, 3 claims
Day Hospital/ Clinic Subject to OAL
and /or In -Room Surgical Subject to OAL
Procedures Cover Subject to OAL
Subject to OAL R4 000 - R850 p/c,
PMB Cover R6 500 - R1 350 p/c, Private ward R1 000 sub-limit
Private ward R2 000 sub-limit R30 000 - R11 500 p/c
Hospital Account Shortfalls
R26 500 p/c, OAL -
Sub-limit Enhancer
R11 000
Step-down

OUT-OF- Primary Care Benefit R5 000, R1250 p/c -
HOSPITAL BENEFITS Day-to-Day Specialist
R6 500, R1 350 p/c, 4 claims p/b R4 500, R950 p/c, 3 claims p/b
Consultation Fee
R12 000 R9 000
Emergency Room Cover Accident & Trauma - Illness 9yrs+ R2000, Accident - stated benefit, Illness 9yrs+ R1 000,
Emergency Illness - children 8yrs & younger Emergency Illness - children 8yrs & younger
Preventative Care Cover
Appliance Benefit R8 000 - R1 250 p/c, R500 R4 500 - R800 p/c, R500
R7 000 R5 000
Trauma Counselling
R8 000 - R950 p/c R4 000, R800 p/c

CANCER Cancer Co-payment Benefit Subject to OAL Subject to OAL
BENEFITS Cancer Benefit - Boost
Subject to OAL Subject to OAL
Cancer Benefit - Breast
Reconstruction 500% for affected breast, 500% for affected breast,
R27 500 for unaffected breast R20 000 for unaffected breast

This benefit category does not form part of the aggregated OAL.

VALUE-ADDED Gap Cover Premium Waiver 6-month period 6-month period
BENEFITS Medical Scheme Up to R5 250 p/m for 6-months Up to R3 750 p/m for 6-months
Premium Waiver
Policyholder - R16 000, Policyholder - R8 500,
Accidental Death Adult - R11 000, Child - R6 000 Adult - R5 500, Child - R3 000

Initial Cancer Diagnosis R27 500 R17 000
R2 000 per newborn child R1 800 per newborn child
Sira’Go Baby
Claims exceeding R9 000 Claims exceeding R9 000
MedCare Cover - Free Medical
Scheme Alternative Dispute

Resolution Service (ADR)

* p/c - Per claim | p/b - Per beneficiary | p/m - Per month. All benefit categories are per policy.
Refer to Policy Wording for full details and explanations. This document is for basic information purposes only.

12 Premiums are reviewed and may be adjusted annually.

Information is subject to change
Premiums are reviewed and may be adjusted annually.

GAP ASSIST GAP LITE GAP ONLY

COVER COVER COVER

Age Premium Age Premium Age Premium Age Premium Age Premium
0-64
0-64 R342 65+ R539 0-64 R249 65+ R369 0-64 R131

0-64 R371 65+ R583 R269 65+ R419 0-64 R172

R191 000 Overall Annual Limit Per Beneficiary Per Annum (from 1 April 2023)

Up to 500% , max 600% Up to 250% , max 350% Up to 200% , max 300%
- - -
-
R42 000 - R11 000 p/c R25 000 - R7 500 p/c -
R6 000 p/c, 1 claim R5 000 p/c, 1 claim
Subject to OAL
Subject to OAL Subject to OAL Subject to OAL

Subject to OAL Subject to OAL -
R3 000. R500 p/c - -
Private ward R1 000 sub-limit - -
-
- -
- -
-
- -
-
R4 500 -
- Accident & Trauma, -
Emergency Illness - children 8yrs & younger -
R6 500
Accident & Trauma -
Emergency Illness - children 8yrs & younger -
-
-
R3 600 - R1 200 p/c

-

R20 000 p/c, Subject to OAL. - -
R50 000 p/b - -
-
- -

This benefit category does not form part of the aggregated OAL.

6-month period - -
- - -
- - -
- - -
R1 500 per newborn child -
R1 500 per newborn child
Claims exceeding R9 000 Claims exceeding R9 000
Claims exceeding R9 000

GENRIC Insurance Company Limited (FSP 43638) 13

Sirago Gap Cover Solutions 2023 Age Limit: none
Overall Annual Limit (OAL) Per
ULTIMATE GAP Beneficiary: R191 000

0 - 64 65+

Individual R498 Individual R714

Family R566 Family R821

Premiums are reviewed and may be adjusted annually. SCAN ME
These benefit categories form part of the aggregated OAL of R191 000.

In-Hospital Benefits PRESCRIBED
MINIMUM BENEFIT
GAP COVER (PMB) COVER
Gap Cover pays the difference between the Prescribed Minimum
medical scheme rate and the rate that service Benefits (PMB) give
providers charge i.e. doctors and specialists. We all scheme members
settle claims at an additional 500% above Medical access to certain
Scheme rate or at the stated benefit value. In the minimum health benefits,
event of a claim for robotic surgery that appears on regardless of
the hospital account. your medical scheme option.
Robotic surgery claims reflect on the hospital Medical schemes are required
account. we will cover up to a sub-limit of R35 000 to pay the full cost of diagnosis and
per policy, limited to R19 000 per claim. treatment of a defined list of medical
The shortfall on claims for BMI (Body Mass Index) conditions. PMB Cover on this policy is for
codes 0018 and 0019 are only paid on the Ultimate the shortfalls resulting from the use of a non-
option. Subject to the OAL. designated service provider for a planned PMB
procedure. This is not applicable in the event of an
CO-PAYMENTS AND CO-PAYMENTS CHARGED emergency. Subject to the OAL.
AS A PERCENTAGE
Co-payment cover is for the co-payments HOSPITAL ACCOUNT SHORTFALLS
(including co-payments expressed as a This benefit will cover any charges on the hospital
percentage), excesses, or deductibles imposed account that the medical scheme has not paid, this
by a medical scheme for specified procedures, includes items like consumables and take-home
cover for hospital admission fees, scans, or surgical medication. We pay up to R6 500 per policy,
procedures. Subject to the OAL. R1 350 per claim. A R2 000 sub-limit is applicable
to private room upgrades. Subject to the OAL.
PENALTY FEE CO-PAYMENTS
This benefit has a sub-limit of R14 000 per claim SUB-LIMIT ENHANCER BENEFIT
and 3 claims per policy irrespective of whether a This benefit has a sub-limit of R26 500 per claim.
rand amount or percentage penalty fee is charged The sub-limit enhancer benefit applies when
by the medical scheme. This is for the voluntary you have exceeded your medical scheme benefit
use of a non-designated service provider or limit for MRI & CT scans, intraocular lenses,
network hospital and includes the use of a partial cochlear implants, and internal prostheses only.
cover network hospital. Subject to the OAL. Subject to the OAL.

DAY HOSPITAL/CLINIC AND/OR IN-ROOM STEP-DOWN
SURGICAL PROCEDURES COVER There is a sub-limit of R11 000 per policy if your
This benefit will cover the shortfall for any medical scheme provides benefits for
day hospital/clinic and/or in-room procedures rehabilitation as an in-patient in a step-down
including acute hospitals if a policyholder elects or sub-acute facility. Cover will be provided for
to have the treatment that would normally be ongoing treatments, resulting from an accident,
performed on an in-patient basis, performed stroke, or cancer treatment, when your medical
as an out-patient, by a registered medical scheme benefit limits have been reached.
professional. Subject to the OAL. Subject to the OAL.

14

Out-Of-Hospital Benefits

EMERGENCY ROOM COVER (Ref 1, 2, 3) the age of 12 years, bone-density scans,
There is a sub-limit of R12 000 for all Emergency prostate-specific antigen tests, mammogram,
Room Cover. This benefit covers an emergency and contraceptive implantation only excluding
at any registered emergency room, hospital, or device.
casualty facility when you require immediate Alternatively, if there is no benefit available at the
medical treatment due to an accident and trauma, time of claim, up to R500 will be paid towards
or illness. We will cover a general practitioner the above tests or treatments, 2 claims per policy.
(GP)’s consultation rooms if no other emergency Subject to the OAL.
facility is available within a 30 km radius.
PRIMARY CARE BENEFIT
Ambulance costs are not covered by this benefit. Primary Care cover is provided for the difference
between the medical scheme rate and the provid-
1. ACCIDENT & TRAUMA BENEFIT er rate of the consultation fee and additional ser-
All costs related to the accident/trauma event will vices charged and included with the consultation
be covered, whether you are liable to pay the costs fee. A sub-limit of R5 000 applies, and R1 250 per
out of your own pocket or if your medical scheme claim. Primary care service providers include:
pays from your savings. • GPs
• Dentists
2. ILLNESS BENEFIT • Alternative therapists (chiropractors,
All costs related to the emergency illness event
will be covered and paid up to R2 000 of the physiotherapists biokineticists, occupational
sub-limit, if you are liable to pay the costs out of therapists, homeopaths, and audiologists,
your own pocket, or if paid from your medical only).
scheme savings. This is applicable to any Subject to the OAL.
beneficiary 9 years and older who needs
emergency treatment outside of normal DAY-TO-DAY SPECIALIST CONSULTATION FEE
consultation hours or treatment that can only be This benefit covers the difference between the
done in an emergency facility. medical scheme rate and the rate charged by the
specialist for the consultation only if your medical
3. CHILD EMERGENCY ILLNESS BENEFIT aid pays a portion of the fee from your available
This benefit is applicable to children 8 years and savings. There is a sub-limit of R6 500 per policy,
younger who require emergency treatment R1 350 per claim, and 4 claims per beneficiary.
for illness out of normal consultation hours or Subject to the OAL.
treatment that can only be done in an emergency
room. All costs related to the event will be covered, APPLIANCE BENEFIT
whether you are liable to pay the costs from your We will pay up to R7 000 per policy for the
own pocket or your medical scheme pays it from difference between the medical scheme
your savings account. benefit amount if there is a rand limit and
what the service provider charges for the
Out of normal consultation hours means 18h00 to following appliances: hearing aids, wheelchairs,
07h00 on Monday to Friday, and all of Saturday, continuous positive airway pressure (CPAP)
Sunday, and South African public holidays. machines, humidifiers, insulin pumps,
Subject to the OAL. glucometers, nebulisers, and Mirena device.
Subject to the OAL.

PREVENTATIVE CARE COVER TRAUMA COUNSELLING
If your medical scheme option makes provision for This benefit covers trauma counselling with a
preventative care benefit a sub-limit of R8 000 will registered medical professional after a traumatic
apply and up to R1 250 per claim. The following event such as, but not limited to: dread disease,
tests or treatments are covered: hijacking, and/or violent crime. A sub-limit of R8
Pap smear, cholesterol test, blood glucose 000 per policy applies, R950 per claim. You will
test, flu vaccination, childhood immunisation be covered within the first 6 months after the
(Department of Health formulary) – up to incident. Subject to the OAL.

Sirago Underwriting Managers (Pty) Ltd is an Authorised Financial Services Provider (FSP: 4710), underwritten by 15
GENRIC Insurance Company Limited (FSP 43638), an Authorised Financial Services Provider and licensed non-life Insurer.

Sirago Gap Cover Solutions 2023

Cancer Benefits

Cancer benefits apply if cancer treatments do not form part of the legislative PMB framework.

CANCER CO-PAYMENT BENEFIT CANCER BREAST RECONSTRUCTION BENEFIT
This benefit applies if your medical scheme After a mastectomy, we will cover up to 500%
cancer benefit has been reached and a of the claim for reconstructive surgery for the
percentage co-payment is imposed. This benefit affected breast, if it is approved by your medical
incorporates co-payments for ongoing cancer- scheme. Up to R27 500 will be paid for the
related treatments and biological drugs. Ongoing reconstruction of the unaffected breast, if there
treatment must be in line with the registered is no payment by the scheme. This benefit is
treatment plan of your medical scheme to access available if the member was on Sirago at the time
this benefit. Subject to the OAL. of the mastectomy or been on Sirago for a year
after transferring from another Gap Provider.
CANCER BOOST BENEFIT Subject to the OAL.
This benefit applies if your medical scheme option
for cancer has a defined rand limit. We will cover For all terms and conditions,
the costs of ongoing treatment in line with the benefits, limitations, and exclusions
medical scheme’s registered treatment plan once please visit https://sirago.co.za, or
the rand limit has been reached.
Subject to the OAL. contact your broker.

Value-Added Benefits

This benefit category does not form part of the aggregated OAL of R191 000.

GAP COVER PREMIUM WAIVER INITIAL CANCER DIAGNOSIS (FIRST
A Premium Waiver benefit may be claimed by DIAGNOSIS)
the surviving spouse or adult dependant on This benefit will pay out a lump sum of
the Sirago policy, in the event of death or total R27 500 on the first ever diagnosis of
permanent disability of the Sirago policyholder. malignant cancer from stage 1. Any cancer
We will keep the premiums for your policy as a prior to inception of the policy or pre-cancer is
credit for 6 months. excluded, specifically skin cancer.

MEDICAL SCHEME PREMIUM WAIVER SIRA’GO BABY
Sirago will pay the rand amount of the medical Sirago will pay out a lump sum of R2 000 for
scheme premium, not higher than R5 250 per your newborn baby when you send us the birth
month for a 6-month period. This will be paid to certificate within 90 days of birth.
the beneficiary for the upkeep of the medical
scheme contributions in event of death or total SIRAGO MEDCARE - FREE MEDICAL SCHEME
permanent disability of the Sirago policyholder ALTERNATIVE DISPUTE RESOLUTION
and where all beneficiaries are linked to a single SERVICE (ADR)
medical scheme. This benefit is only payable for With this benefit, the policyholder will get access
the medical scheme that the policyholder was to MedCare’s free ADR service for all disp uted PMB
on if there is dual medical scheme membership. claims exceeding R9 000. Policyholders can also
access the MedCare service for all claims less than
ACCIDENTAL DEATH R9 000, including all potential medical scheme
This benefit will pay out for accidental death: disputes, at a 60%, 20%, and/or 15% discounted
at R16 000 for the Sirago policyholder, R11 000 rate depending on the required service.
for the adult dependant, and R6 000 for child
dependants. Your broker can also access this service on your
behalf and will subsequently have access to the
MedCare website: siragomedcare.co.za

Sirago Underwriting Managers (Pty) Ltd is an Authorised Financial Services Provider (FSP: 4710), underwritten by

16 GENRIC Insurance Company Limited (FSP 43638), an Authorised Financial Services Provider and licensed non-life Insurer.

PLUS GAP Age Limit: none
Overall Annual Limit (OAL) Per
Beneficiary: R191 000

0 - 64 65+

Individual R395 Individual R615

Family R452 Family R701

Premiums are reviewed and may be adjusted annually. SCAN ME
These benefit categories form part of the aggregated OAL of R191 000.

In-Hospital Benefits

GAP COVER DAY HOSPITAL/CLINIC AND/OR IN-ROOM
Gap Cover pays the difference between the SURGICAL PROCEDURES COVER
medical scheme rate and the rate that service This benefit will cover the shortfall for any
providers charge i.e. doctors and specialists. day hospital/clinic and/or in-room procedures
We cover up to 500% above your medical including acute hospitals if a policyholder
scheme rates or at the stated benefit value, to a elects to have the treatment that would
maximum of 600%. normally be performed on an in-patient basis,
performed as an out-patient, by a registered
Robotic surgery claims reflect on the hospital medical professional. Subject to the OAL.
account. In the event of a claim for robotic
surgery that appears on the hospital account. PRESCRIBED MINIMUM BENEFIT (PMB)
We will cover up to a sub-limit of R18 000 COVER
per policy, limited to R6 000 per claim, per Prescribed Minimum Benefits (PMB) give all
beneficiary. Subject to the OAL. scheme members access to certain minimum
health benefits, regardless of your medical
CO-PAYMENTS AND CO-PAYMENTS CHARGED scheme option. Medical schemes are required
AS A PERCENTAGE to pay the full cost of diagnosis and treatment of
Co-payment cover is for the co-payments a defined list of medical conditions. PMB Cover
(including co-payments expressed as a on this policy is for the shortfalls resulting from
percentage), excesses, or deductibles imposed the use of a non-designated service provider for
by a medical scheme for specified procedures, a planned PMB procedure. This is not applicable
cover for hospital admission fees, scans, or in the event of an emergency.
surgical procedures. Subject to the OAL. Subject to the OAL.

PENALTY FEE CO-PAYMENTS HOSPITAL ACCOUNT SHORTFALLS
This benefit has a sub-limit of R9 500 per claim This benefit will cover any charges on the
and 1 claim per policy irrespective of whether hospital account that the medical scheme
a rand amount or percentage penalty fee is has not paid for, this includes items like
charged by the medical scheme. This is for consumables and take-home medication. We
the voluntary use of a non-designated service pay up to R4 000 per policy, R850 per claim. A
provider or network hospital and includes the R1 000 sub-limit is applicable to private room
use of a partial cover network hospital. upgrades. Subject to the OAL.
Subject to the OAL.
SUB-LIMIT ENHANCER BENEFIT
ffRoorreafceedlxarmcitmlouinsdtihesreetdrlaaCf ttraeioondmnctecocrhocCavaoerng-rpceoeasnyra.mtCrheoeissn-ppptaeoBycleimicfniyece. anfilttlsy This benefit has a sub-limit of R30 000 per
policy and R11 500 per claim. The sub-limit
enhancer benefit applies when you have
exceeded your medical scheme benefit limit for
MRI & CT scans, and internal prostheses only.
Subject to the OAL.

GENRIC Insurance Company Limited (FSP 43638) 17

Sirago Gap Cover Solutions 2023

Out-Of-Hospital Benefits

EMERGENCY ROOM COVER (Ref 1, 2, 3) PREVENTATIVE CARE COVER
A sub-limit of R9 000 is applicable for all If your medical scheme option makes provision
Emergency Room Cover. This benefit covers for preventative care benefits, a sub-limit of
an emergency at any registered emergency, R4 000 will apply. Claims will be paid up to R800
hospital, or casualty facility when you require per claim. The following tests or treatments
immediate medical treatment due to an are covered: Pap smear, cholesterol test,
accident and trauma, or illness. We will cover a blood glucose test, flu vaccination, childhood
general practitioner (GP)’s emergency facility immunisation (Department of Health
if no emergency hospital is available within a formulary) – up to the age of 12 years, bone-
30km radius. density scans, prostate-specific antigen tests,
mammogram, and contraceptive implantation
Ambulance costs are not covered by this only excluding device. Alternatively, if there is
benefit. no benefit available at the time of claim, up to
R500 will be paid towards the cost of the above
1. ACCIDENT & TRAUMA BENEFIT treatments or tests, 2 claims per policy.
All costs related to the accident/ trauma event Subject to the OAL.
will be covered, whether you are liable to pay the
costs out of your own pocket or if your medical DAY-TO-DAY SPECIALIST CONSULTATION FEE
scheme pays from your savings. This benefit covers the difference between the
medical scheme rate and the rate charged
2. ILLNESS BENEFIT by the specialist for consultation only if your
All costs related to the emergency illness medical aid pays a portion of the fee from your
event will be covered and paid up to R1 000 of available savings. There is a sub-limit of R4 500
the sub-limit, if you are liable to pay the costs per policy, R950 per claim, and 3 claims per
out of your own pocket, or if paid from your beneficiary. Subject to the OAL.
medical scheme savings. This is applicable to
any beneficiary 9 years and older who needs APPLIANCE BENEFIT
emergency treatment outside of normal We will pay up to R5 000 per policy for the
consultation hours or treatment that can only difference between what the medical scheme
be done in an emergency room. benefit amount if there is a rand limit and what
the service provider charges for the following
3. CHILD EMERGENCY ILLNESS BENEFIT appliances: hearing aids, wheelchairs,
This benefit is applicable to children 8 years and continuous positive airway pressure (CPAP)
younger who require emergency treatment machines, humidifiers, insulin pumps,
for illness out of normal consultation hours glucometers, nebulisers, and Mirena device.
or treatment that can only be done in an Subject to the OAL.
emergency room. All costs related to the event
will be covered, whether you are liable to pay TRAUMA COUNSELLING
the costs from your own pocket or your medical This benefit covers trauma counselling with a
scheme pays it from your savings account. registered medical professional after a traumatic
event such as, but not limited to: dread disease,
Out of normal consultation hours means hijacking, and/or violent crime. A sub-limit of
18h00 to 07h00 on Monday to Friday, and all R4 000 per policy applies, R800 per claim.
of Saturday, Sunday, and South African public You will be covered within the first 6 months
holidays. Subject to the OAL. after the incident. Subject to the OAL.

For all terms and conditions,
benefits, limitations, and exclusions
please visit https://sirago.co.za, or

contact your broker.

18

Cancer Benefits

Cancer benefits apply if cancer treatments do not form part of the legislative PMB framework.

CANCER CO-PAYMENT BENEFIT CANCER BREAST RECONSTRUCTION BENEFIT
This benefit applies if your medical scheme After a mastectomy, we will cover up to 500%
cancer benefit has been reached and a of the claim for reconstructive surgery for
percentage co-payment is imposed. This the affected breast, if it is approved by your
benefit incorporates co-payments for ongoing medical scheme.
cancer-related treatments and biological drugs.
Ongoing treatment must be in line with the Up to R20 000 will be paid for the
registered treatment plan of your medical reconstruction of the unaffected breast,
scheme to access this benefit. if there is no payment by the scheme. This
Subject to the OAL. benefit is available if the member was on
Sirago at the time of the mastectomy or been
CANCER BOOST BENEFIT on Sirago for a year after transferring from
This benefit applies if your medical scheme another Gap Provider. Subject to the OAL.
option for cancer has a defined rand limit.
We will cover the costs of ongoing treatment
in line with the medical scheme’s registered
treatment plan once the rand limit has been
reached. Subject to the OAL.

Value-Added Benefits

This benefit category does not form part of the aggregated OAL of R191 000.

GAP COVER PREMIUM WAIVER INITIAL CANCER DIAGNOSIS (FIRST
A Premium Waiver benefit may be claimed by DIAGNOSIS)
the surviving spouse or adult dependant on This benefit will pay out a lump sum of
the Sirago policy in the event of death or total R17 000 on the first-ever diagnosis of
permanent disability of the Sirago policyholder. malignant cancer from stage 1. Any cancer
We will keep the premiums for your policy as a prior to inception of the policy or pre-cancer is
credit for 6 months. excluded, specifically skin cancer

MEDICAL SCHEME PREMIUM WAIVER SIRA’GO BABY
Sirago will pay the rand amount of the medical Sirago will pay out a lump sum of R1 800 for
scheme premium, not higher than R3 750 per your newborn baby when you send us the birth
month for a 6-month period. This will be paid to certificate within 90 days of birth.
the beneficiary for the upkeep of the medical
scheme contributions in event of death or total SIRAGO MEDCARE - FREE MEDICAL SCHEME
permanent disability of the Sirago policyholder ALTERNATIVE DISPUTE RESOLUTION
and where all beneficiaries are linked to a single SERVICE (ADR)
medical scheme. This benefit is only payable for If a PMB claim does not qualify as a valid claim,
the medical scheme that the policyholder was you will have access to MedCare’s free
on if there is dual medical scheme membership. alternative dispute resolution (ADR) service for
all claims exceeding R9 000. You can also ac-
ACCIDENTAL DEATH cess the MedCare service for all claims less than
This benefit will pay out for accidental death: R9 000, including all potential medical scheme
at R8 500 for the Sirago policyholder, R5 500 disputes, at a 60%, 20%, or 15% discounted rate
for the adult dependant, and R3 000 for child depending on the required service.
dependants. Your financial advisor can also access this
service on your behalf and will have access to
the MedCare website: siragomedcare.co.za

Sirago Underwriting Managers (Pty) Ltd is an Authorised Financial Services Provider (FSP: 4710), underwritten by 19
GENRIC Insurance Company Limited (FSP 43638), an Authorised Financial Services Provider and licensed non-life Insurer.

Sirago Gap Cover Solutions 2023

GAP ASSIST Age Limit: none
Overall Annual Limit (OAL) Per
Beneficiary: R191 000

0 - 64 65+

Individual R342 Individual R539

Family R371 Family R583

Premiums are reviewed and may be adjusted annually. SCAN ME
These benefit categories form part of the aggregated OAL of R191 000.

In-Hospital Benefits

GAP COVER DAY HOSPITAL/CLINIC AND/OR IN-ROOM
Gap Cover pays the difference between the SURGICAL PROCEDURES COVER
medical scheme rate and the rate that service This benefit will cover the shortfall on any day
providers charge i.e. doctors and specialists. hospital/clinic and/or in-room procedures if you
We cover up to 500% above your medical elect to have the treatment that would normally
scheme rates or at the stated benefit value, to a be performed in-hospital as an out-patient.
maximum of 600%. Subject to the OAL. Subject to the OAL.

CO-PAYMENTS AND CO-PAYMENTS CHARGED PRESCRIBED MINIMUM BENEFIT (PMB)
AS A PERCENTAGE COVER
Co-payment cover is for the co-payments Prescribed Minimum Benefits (PMB) give all
(including co-payments expressed as a scheme members access to certain minimum
percentage), excesses, or deductibles imposed health benefits, regardless of your medical
by a medical scheme for specified procedures, scheme option. Medical schemes are required
cover for hospital admission fees, scans, or to pay the full cost of diagnosis and treatment of
surgical procedures. Co-payments will be paid a defined list of medical conditions. PMB Cover
up to a sub-limit of R42 000 per policy, up on this policy is for the shortfalls resulting from
R11 000 per claim. Subject to the OAL. the use of a non-designated service provider for
a planned PMB procedure. This is not applicable
PENALTY FEE CO-PAYMENTS in the event of an emergency.
This benefit has a sub-limit of R6 000 per claim Subject to the OAL.
and 1 claim per policy irrespective of whether
a rand amount or percentage penalty fee is HOSPITAL ACCOUNT SHORTFALLS
charged by the medical scheme. This is for This benefit will cover any charges on the
the voluntary use of a non-designated service hospital account that the medical scheme
provider or network hospital and includes the has not paid for, this includes items like
use of a partial cover network hospital. consumables and take-home medication.
Subject to the OAL. We pay up to R3 000 per policy, R500 per claim,
3 claims per beneficiary. A R1 000 sub-limit is
applicable to private room upgrades.
Subject to the OAL.

Out-Of-Hospital Benefits

APPLIANCE BENEFIT #DidYouKnow:
We will pay up to R3 600 per policy and Our minimum claim amount is R100
R1 200 per claim for the difference between GENRIC Insurance Company Limited (FSP 43638)
the medical scheme benefit amount if there
is a rand limit and what the service provider
charges for the following appliances: hearing
aids, wheelchairs, continuous positive airway
pressure (CPAP) machines, humidifiers,
insulin pumps, glucometers, nebulisers, and
Mirena device. Subject to the OAL.

20

EMERGENCY ROOM COVER (Ref 1, 2, 3) 2. ILLNESS BENEFIT
There is a sub-limit of R6 500 for all Emergency There is no benefit for Emergency Illness for
Room Cover. This benefit covers an emergency any beneficiary on the Sirago policy 9 years
at any registered emergency, hospital, or and older.
casualty facility when you require immediate
medical treatment due to an accident and 3. CHILD EMERGENCY ILLNESS BENEFIT
trauma, or illness. We will cover a general This benefit is applicable to children 8
practitioner (GP)’s emergency facility if no years and younger who require emergency
emergency hospital is available within a 30 km treatment for illness out of normal
radius. consultation hours or treatment that can
only be done in an emergency room. All costs
Ambulance costs are not covered by this benefit. related to the event will be covered, whether
you are liable to pay the costs from your own
1. ACCIDENT & TRAUMA BENEFIT pocket or your medical scheme pays it from
All costs related to the accident/ trauma event your savings account.
will be covered, whether you are liable to pay the
costs out of your own pocket or if your medical Out of normal consultation hours means
scheme pays from your savings. 18h00 to 07h00 on Monday to Friday, and all
of Saturday, Sunday, and South African public
holidays.

Cancer Benefits

Cancer benefits apply if cancer treatments do not form part of the legislative
PMB framework.

CANCER CO-PAYMENT BENEFIT CANCER BOOST BENEFIT
This benefit applies if your medical scheme This benefit applies if your
cancer benefit has been reached and a medical scheme option
percentage co-payment is imposed. This for cancer has a defined
benefit incorporates co-payments for ongoing rand limit. We will cover the
cancer-related treatments and biological drugs. costs of ongoing treatment
Ongoing treatment must be in line with the in line with the medical
registered treatment plan of your medical scheme’s registered
scheme to access this benefit, up to R20 000 treatment plan, once the
per claim. Subject to the OAL. rand limit has been reached.
There is a sub-limit of R50 000
per beneficiary for all claims.
Subject to the OAL.

Value-Added Benefits

This benefit category does not form part of the aggregated OAL of R191 000.

GAP COVER PREMIUM WAIVER SIRAGO MEDCARE - FREE MEDICAL
A Premium Waiver benefit may be claimed by SCHEME ALTERNAIVE DISPUTE
the surviving spouse or adult dependant on RESOLUTION SERVICE (ADR)
the Sirago policy in the event of death or total If a PMB claim does not qualify as a valid
permanent disability of the Sirago policyholder. claim, you will have access to MedCare’s free
We will keep the premiums for your policy as a alternative dispute resolution (ADR) service
credit for 6 months. for all claims exceeding R9 000. You can also
access the MedCare service for all claims less
SIRA’GO BABY than R9 000, including all potential medical
Sirago will pay out a lump sum of R1 500 for scheme disputes, at a 60%, 20%, or 15%
your newborn baby when you send us the birth discounted rate depending on the required
certificate within 90 days of birth. service. Your financial advisor can also access
this service on your behalf and will have access
to the MedCare website: siragomedcare.co.za.

21

Sirago Gap Cover Solutions 2023 Age Limit: none
Overall Annual Limit (OAL) Per
GAP LITE Beneficiary: R191 000

0 - 64 65+

Individual R249 Individual R369

Family R269 Family R419

Premiums are reviewed and may be adjusted annually. SCAN ME
These benefit categories form part of the aggregated OAL of R191 000.

In-Hospital Benefits

GAP COVER DAY HOSPITAL/CLINIC AND/OR IN-ROOM
Gap Cover pays the difference between the SURGICAL PROCEDURES COVER
medical scheme rate and the rate that service This benefit will cover the shortfall on any day
providers charge i.e. doctors and specialists. hospital/clinic and/or in-room procedures if you
We cover up to 250% above your medical elect to have the treatment that would normally
scheme rates or at the stated benefit value, to a be performed in-hospital as an out-patient.
maximum of 350%. Subject to the OAL. Subject to the OAL.

CO-PAYMENTS AND CO-PAYMENTS CHARGED PRESCRIBED MINIMUM BENEFIT (PMB) COVER
AS A PERCENTAGE Prescribed Minimum Benefits (PMB) give all
Co-payment cover is for the co-payments scheme members access to certain minimum
(including co-payments expressed as a health benefits, regardless of your medical
percentage), excesses, or deductibles imposed scheme option. Medical schemes are required to
by a medical scheme for specified procedures, pay the full cost of diagnosis and treatment of a
cover for hospital admission fees, scans, or defined list of medical conditions. PMB Cover on
surgical procedures. Co-payments will be paid this policy is for the shortfalls resulting from the
up to a sub-limit of R25 000 per policy, up to use of a non-designated service provider for a
R7 500 per claim. Subject to the OAL. planned PMB procedure. This is not applicable in
the event of an emergency. Subject to the OAL.
PENALTY FEE CO-PAYMENTS
This benefit has a sub-limit of R5 000 per claim, bpelneFaeosfiertsav,lillsitmiterhimttattspioasnn:/s/ds, iacrnoandgdoei.xtcicool.unzssai,,oonrs
per policy irrespective of whether a rand amount contact your broker.
or percentage penalty fee is charged by the
medical scheme. This is for the voluntary use of
a non-designated service provider or network
hospital and includes the use of a partial-cover
network hospital. Subject to the OAL.

22 Underwritten by GENRIC Insurance

Out-Of-Hospital Benefits

EMERGENCY ROOM COVER (Ref 1, 2, 3) 2. ILLNESS BENEFIT
There is a sub-limit of R4 500 for Emegency There is no benefit for Emergency Illness for any
Room cover. This benefit covers an emergency at beneficiary on the Sirago policy 9 years and older
any registered emergency, hospital, or casualty
facility when you require immediate medical 3. CHILD EMERGENCY ILLNESS BENEFIT
treatment due to an accident and trauma, or This benefit is applicable to children 8 years and
illness. We will cover a general practitioner (GP)’s younger who require emergency treatment
emergency facility if no emergency hospital is for illness out of normal consultation hours
available within a 30 km radius. or treatment that can only be done in an
emergency room. All costs related to the event
Ambulance costs are not covered by this benefit. will be covered, whether you are liable to pay
the costs from your own pocket or your medical
1. ACCIDENT & TRAUMA BENEFIT scheme pays it from your savings account.
All costs related to the accident/ trauma event
will be covered, whether you are liable to pay the Out of normal consultation hours means
costs out of your own pocket or if your medical 18h00 to 07h00 on Monday to Friday, and all
scheme pays from your savings. of Saturday, Sunday, and South African public
holidays. Subject to the OAL.

Value-Added Benefits

This benefit category does not form part of the aggregated OAL of R191 000.

SIRA’GO BABY all claims exceeding R9 000. You can also access
Sirago will pay out a lump sum of R1 500 for the MedCare service for all claims less than
your newborn baby when you send us the birth R9 000, including all potential medical scheme
certificate within 90 days of birth. disputes, at a 60%, 20%, or 15% discounted rate
depending on the required service.
SIRAGO MEDCARE - FREE MEDICAL SCHEME
ALTERNATIVE DISPUTE RESOLUTION SERVICE Your financial advisor can also access this service
(ADR) on your behalf and will have access to the
If a PMB claim does not qualify as a valid MedCare website: siragomedcare.co.za.
claim, you will have access to MedCare’s free
alternative dispute resolution (ADR) service for

Sirago Underwriting Managers (Pty) Ltd is an Authorised Financial Services Provider (FSP: 4710), underwritten by
GENRIC Insurance Company Limited (FSP 43638), an Authorised Financial Services Provider and licensed non-life Insurer.

Sirago Gap Cover Solutions 2023 Age Limit: none
Overall Annual Limit (OAL) Per
GAP ONLY Beneficiary: R191 000

0 - 64

Individual R131

Family R172

Premiums are reviewed and may be adjusted annually. SCAN ME
These benefit categories form part of the aggregated OAL of R191 000.

In-Hospital Benefits

GAP COVER PRESCRIBED MINIMUM BENEFIT (PMB)
Gap Cover pays the difference between the COVER
medical scheme rate and the rate that service Prescribed Minimum Benefits (PMB) give all
providers charge i.e. doctors and specialists. We scheme members access to certain minimum
cover up to 200% above your medical scheme health benefits, regardless of your medical
rates or at the stated benefit value, to a maximum scheme option. Medical schemes are required
of 300%. Subject to the OAL. to pay the full cost of diagnosis and treatment
of a defined list of medical conditions.
DAY HOSPITAL/CLINIC AND/OR IN-ROOM
SURGICAL PROCEDURES COVER PMB Cover on this policy is for the shortfalls
This benefit will cover the shortfall on any day resulting from the use of a non-designated
hospital/clinic and/or in-room procedures if you service provider for a planned PMB procedure.
elect to have the treatment that would normally This is not applicable in the event of an
be performed in-hospital as an out-patient. emergency.
Subject to the OAL. Subject to the OAL.

Value-Added Benefits

This benefit category does not form part of the aggregated OAL of R191 000.

SIRAGO MEDCARE - FREE MEDICAL SCHEME You can also access the MedCare service
ALTERNATIVE DISPUTE RESOLUTION SERVICE for all claims less than R9 000, including all
(ADR) potential medical scheme disputes, at a 60%,
If a PMB claim does not qualify as a valid claim, 20%, or 15% discounted rate depending on the
you will have access to MedCare’s free alternative required service.
dispute resolution (ADR) service for all claims
exceeding R9 000. Your financial advisor can also access this
service on your behalf and will have access to
the MedCare website: siragomedcare.co.za.

24 Underwritten by GENRIC Insurance

CORPORATE SOLUTIONS

WHAT IS CORPORATE GAP COVER?

Sirago Corporate Gap Cover was designed specifically to meet the needs of the corporate
market and offers a range of comprehensive Gap cover options:

• Ultimate Gap Cover
• Plus Gap Cover
• Gap Assist Cover
• Exact Cover
• Exact with Gap & Co-pay Cover

CORPORATE PREMIUMS

Our Corporate product is available to employer groups with 10 or more employees participating on
a medical scheme. Premiums are determined using a number of actuarial-based criteria in order
to ensure sustainability, consistency, and protection of both the employer group, the policyholder,
and the Insurer. Upon request, the following criteria, amongst others, is taken into consideration
in determining premiums:

Group size Average age of employee base

Geographical location Medical scheme option

Individual vs family within the
Compulsory or voluntary participation employer group



While we endeavor to provide competitive quotes, the information received will determine the
outcome. In addition to this, standard underwriting terms (new business versus transfer of cover)
would also be considered to ensure a stronger alignment with the current employer and broker
structures.

Depending on the employer needs and whether it is voluntary or compulsory, premium proposals
will be presented on either a flat rate or age-based in conjunction with family structures.

#FUTUREBUILTGENRIC Insurance Company Limited (FSP 43638)
ENTHUSIASM IS COMMON

RESILIENCE IS RARE

25

Sirago Gap Cover Solutions 2023

EXACT COVER Age Limit: none
Overall Annual Limit (OAL) Per
Beneficiary: R140 000

0 - 64 65+

Individual R195 Individual R412
Family R508
Family R225 SCAN ME

Premiums are reviewed and may be adjusted annually.

WHAT IS EXACT COVER?

Our Exact Cover product provides access to a defined list of stated
procedures when your Medical scheme option excludes those specific
procedures over and above their standard exclusions. Sirago will negotiate
with all service providers on your behalf and pay the claim directly, up to the

stated amounts as listed below. The cost of the hospital and all service
providers are included in the cover limits.

COVER LIMITS

Arthroscopic surgery R75 000 Joint replacement surgery R50 000
Back and neck surgery R75 000 Oesophageal reflux and hiatus hernia R60 000
Bunion surgery R20 000 surgery R22 500
Cochlear implant, auditory brain implant R85 000 Varicose vein surgery R20 000
and internal nerve Stimulator surgery, Knee and shoulder surgery R10 000
including the device and processor R80 000 MRI and CT scans due to an accident
Dental procedures for reconstructive plastic Emergency casualty benefit: R6 000
surgery due to an accident R15 000 Accident & Trauma,
Dental procedures for impacted wisdom Children under 8 years old (max R4 000) R20 000
teeth for children under 18 years old Skin disorders including benign growths R20 000
and lymphoma R5 000
Functional nasal surgery R25 000 Non-cancerous breast conditions
Endoscopic procedures

26 Underwritten by GENRIC Insurance

EXACT COVER EXCLUSIONS

• Medical procedures listed as specific exclusions by your medical scheme that are not on our list
of medical procedures.

• Sirago’s listed procedures if your medical scheme paid a portion towards the account.
• Any shortfalls after Sirago has paid the cover limit for the authorised procedure.

WAITING PERIODS FOR EXACT COVER

• A 10-month waiting period applies where no claims can be submitted for a procedure or
surgery related to our list of procedures.

• A 12-month waiting period on pre-existing conditions, specific diseases and/or illnesses related
to our list of procedures.

#DIDYOUKNOW

Sirago entered the niche insurance market as SAFCAM in 1993, pioneering Gap cover.
In 2005, our name changed to Resolution Underwriters, and in 2010 it became what we

are known as today - Sirago Underwriting Managers (Pty) Ltd.

Sirago Underwriting Managers (Pty) Ltd is an Authorised Financial Services Provider (FSP: 4710), underwritten by
GENRIC Insurance Company Limited (FSP 43638), an Authorised Financial Services Provider and licensed non-life Insurer.

27

Sirago Gap Cover Solutions 2023

EXACT COVER WITH GAP & CO-PAY

Exact cover Gap and Co-pay
Age Limit: none Age Limit: none
Overall Annual Limit (OAL) Per Overall Annual Limit (OAL) Per
Beneficiary: R140 000 Beneficiary: R191 000

0 - 64 65+

Individual R349 Individual R737
Family R887
Family R395 SCAN ME

Premiums are reviewed and may be adjusted annually.

WHAT IS EXACT WITH GAP AND CO-PAY COVER?

The Exact with Gap and Co-Pay option provides cover for specific procedures that
your medical scheme excludes, with additional Gap and Co-payment cover.

The Exact Cover option provides access to a defined list of stated procedures when
your Medical scheme option excludes those specific procedures over and above
their standard exclusions. Sirago will negotiate with all service providers on your
behalf and pay the claim directly, up to the stated amounts as listed below.
The cost of the hospital and all service providers are included in the cover limit.

EXACT COVER
COVER LIMITS FOR EXACT

Arthroscopic surgery R75 000 Joint replacement surgery R50 000
Back and neck surgery R75 000 Oesophageal reflux and hiatus hernia R60 000
Bunion surgery R20 000 surgery R22 500
Cochlear implant, auditory brain implant R85 000 Varicose vein surgery R20 000
and internal nerve Stimulator surgery, Knee and shoulder surgery R10 000
including the device and processor R80 000 MRI and CT scans due to an accident
Dental procedures for reconstructive plastic Emergency casualty benefit: R6 000
surgery due to an accident R15 000 Accident & Trauma
Dental procedures for impacted wisdom Children under 8 years old (max R4 000) R20 000
teeth for children under 18 years old Skin disorders including benign growths R20 000
and lymphomas R5 000
Functional nasal surgery R25 000 Non-cancerous breast conditions
Endoscopic procedures

EXACT COVER EXCLUSIONS

• Medical procedures listed as specific exclusions by your medical scheme that are not on our list
of medical procedures.

• Sirago’s listed procedures, if your medical scheme paid a portion towards the account.
• Any shortfalls after Sirago has paid the cover limit for the authorised procedure.

28 GENRIC Insurance Company Limited (FSP 43638)

WAITING PERIODS FOR EXACT COVER

• A 10-month waiting period applies where no claims can be submitted for a procedure or surgery
related to our list of procedures.

• A 12-month waiting period on pre-existing conditions, specific diseases and/or illnesses related to
our list of procedures.

GAP & CO-PAY COVER

In-Hospital Benefits

GAP COVER
Gap cover pays the difference between the medical scheme rate and the rate that service providers
charge i.e. doctors and specialists. We cover up to 300% above your medical scheme rates or at the
stated benefit value, to a maximum of 400%. Subject to the OAL.
CO-PAYMENTS
Co-payment cover is for the co-payments (including co-payments expressed as a percentage),
excesses, or deductibles imposed by a medical scheme for specified procedures, cover for hospital
admission fees, scans, or surgical procedures.
Sirago will pay up to R21 000 per policy, R7 000 per claim. Subject to the OAL.

Value-Added Benefits

This benefit category does not form part of the aggregated OAL of R191 000.
GAP COVER PREMIUM WAIVER
A Premium Waiver benefit may be claimed by the surviving spouse or adult dependant on the Sirago
policy in the event of death or total permanent disability of the Sirago policyholder. We will keep the
premiums for your policy as a credit for 6 months.
ACCIDENTAL DEATH
This benefit will cover the accidental death of the policyholder at R5 000.

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contact your broker.

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Sirago Gap Cover Solutions 2023

IMPORTANT

TERMS & CONDITIONS

EXCLUSIONS - WHAT SIRAGO DOES NOT amount or percentage of cost. The Medical
PAY FOR scheme should be responsible for the first
Sirago will not pay for any illness, condition, 100% or 200% of the claim, according to your
disease or injury, or the consequences or Medical scheme option.
treatment resulting from or associated with: • Claims that exceed the limit of each benefit
category.
• Benefits that your Medical Scheme excludes • Out-patient or day-to-day treatment,
or does not pay for, or has not paid a portion consultations , investigations, or surgical
of the claim, or if you have used up your whole procedures unless there is a specific benefit
benefit limit on the Medical scheme. on your Sirago option.
• The cost of any experimental treatments and
• If there is no authorisation from the Medical medication, both in and out of hospital are
scheme and they do not pay, neither does not covered.
Sirago. • Any claim less than the minimum claim
amount of R100.
• Sirago has certain stated benefits that are not • Claims for organ donations and recipients do
related to claims from the Medical scheme. not have any benefit entitlement.

• The first 100% of the medical scheme tariff
or rate for any claim, unless it is a scheme-
imposed co-payment charged as a rand

GENERAL POLICY EXCLUSIONS received medical advice, received treatment
Sirago will not compensate you for any
illness, condition, disease or injury, or the by a registered medical professional or
consequences or treatment resulting from or
associated with: exhibited symptoms before the actual

• An event not covered by this policy and/or inception of the policy.
falling outside of the policy’s intention.
• Breast reconstruction and breast
• An event where pre-authorisation was not
obtained from the medical scheme or where reconstruction performed as a secondary or
medical scheme rules were not adhered to.
subsequent reconstruction, unless part of
• Any claim that must be paid in terms of
alternate proclaimed legislation, such as the the benefit entitlement of your Sirago option.
Compensation for Occupational Injuries Act
90 of 1993, and the Road Accident Fund Act • Intraocular lenses, unless part of the benefit
56 of 1996.
entitlement of your Sirago option.
• Any dependant not noted on the policy on
the incident date. • Claims for regular or routine medical

• Any pre-existing condition, disease, disorder, treatment or advice on an on-going basis,
or illness, for the first 10 months. This will
include any condition which existed before and routine physical examinations or
inception, whether diagnosed or not, or
for which an insured person has sought or procedures purely of a diagnostic nature,
received medical advice, received treatment
by a registered medical professional, or except as listed under the Preventative Care
exhibited symptoms, before the actual
inception of the policy. benefit.

• Any pre-existing cancer condition, disease, • Any illness, injury, or consequence of alcohol,
disorder, or illness, for the first 12 months.
This will include any condition which existed drug or substance intoxication, use, abuse,
before inception, whether diagnosed or not,
or for which an insured person has sought or or addiction, whether directly or indirectly

traceable to the insured being affected

permanently or temporarily. Claims may

be considered where registered drugs are

administered and prescribed by a registered

medical professional.

• Any psychiatric or psychological condition,

emotional or nervous conditions including,

but not limited to depression, insanity,

psychosis, stress-related and affective

disorders, unless specified as part of a benefit

entitlement.

• Suicide, attempted suicide, or any intentional

or deliberate self-injury and/or self-exposure

30 GENRIC Insurance Company Limited (FSP 43638)

to danger or risk except to save a human life. for management of overweight
• Medication (chronic or acute), drugs, and underweight patients for BMI. BMI
codes 0018 and 0019 are not covered,
prescriptions, consumables, and equipment unless specified as part of the benefit
used, unless they are part of the benefit entitlement.
entitlement.
• Devices, such as artificial joints, braces, b) Sirago will pay the additional charges
crutches, dental implants, orthodontic, by a Registered Medical Professional for
prosthodontic and all cosmetic dentistry the management of overweight and
including all forms of internal and external underweight patients for BMI claims,
prostheses as defined, unless specified as part only if directly related to pregnancy and
of the benefit entitlement of this policy. diseases that are non-lifestyle related.
• Cosmetic surgery where there is no clinical • Investigations, treatment, or surgery related
indication for treatment, including any
treatment and costs resulting from these to infertility, artificial insemination, hormone
procedures, unless specified as part of the treatment for infertility, or any other form of
option benefit entitlement. assisted reproduction.
• Discounts negotiated directly with a service • Any claim related to contraceptive device
provider and the insured person and where implantation, unless specified in option’s
reimbursement of a claim would benefit or benefit entitlement.
enrich. • Robotic surgery including specialised
• Elective procedures that have no clinical or mechanical or computerised appliances
medical indication, including any treatment and equipment, unless your Sirago option
and costs resulting from these procedures, specifically makes provision for this type of
unless specified as part of the benefit cover.
entitlement.
• Investigations, treatment, or surgery for eating SPORT RELATED EXCLUSIONS:
disorders, obesity, or weight management, a) Any illness, injury or condition resulting
including any consequence of such
treatment. from, or directly associated with
• Investigations, treatment, medication, or professional sport as a paid profession.
surgery related to any condition where
advice, diagnosis and/or treatment is received b) Participation in any form of race or speed
outside the borders of South Africa. test, other than on foot.
• BMI (Body Mass Index)
c) Sports involving any mechanically
a) The additional charge on claims by propelled vehicles or crafts.
Registered Medical Professional
d) Participation in a sport that is defined
as hazardous or dangerous, except for
scholars taking part in school activities.

STANDARD SHORT-TERM POLICY • The act of any lawfully established authority,
EXCLUSIONS police force, security force, or any other local,
Sirago will not pay for any illness, condition, provincial, or national body, in controlling,
disease or injury, or the consequences or preventing, suppressing or in any other way
treatment resulting from or associated with: dealing with any event referred to in the
clauses above.
• Any claim arising directly or indirectly from
active involvement in war, invasion, an act • Compensation in terms of the War Damage
of a foreign enemy, hostilities (whether Insurance Act 85 of 1976.
war be declared or not), civil war, rebellion,
revolution, insurrection or political risk of any • Nuclear weapons or nuclear material, ionizing
kind, or any act of any person acting on behalf radiation, or contamination by radioactivity
of or in connection with any organisation, from any nuclear fuel or from any nuclear
group or activity aimed at overthrowing any waste from the combustion of nuclear fuel.
government by force or any deliberate act of For this exception combustion shall include
terrorism or violence. any self-sustaining process of nuclear fission.

• Any riot, strike, or public disorder (including • Any loss arising from any contractual liability.
civil commotion, labour disturbances or • Any consequential loss or damage
lock-out) or any act or activity resulting in, or
calculated to bring about a riot, strike, or such whatsoever.
disorder. • Any attempt by you to commit an unlawful

• Active military duty, police duty, police act.
reservist duty, civil commotion, labour
disturbances, riot, strike, or the activities of The above is a summary of the terms
locked-out workers. and conditions. For a concise list, please refer

to the Policy Wording which forms part of
your Schedule of Insurance.

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