GAP

COVER
FROM

www.totalrisksa.co.za
Total Risk Administrators (Pty) Ltd
(TRA) an authorised financial services
R99 PER MONTH
provider FSP No 40815

DON’T STRESS! THE GAP IS COVERED.

GAP COVER Medical Shortfall Cover

THE FOLLOWING BENEFITS ARE SUBJECT TO AN AGGREGATE ANNUAL LIMIT OF R210 580 PER INSURED PERSON
2025
This amount is calculated annually according to the prescribed table under Regulation 7.2(1) of Regulation 7.2(2) - Policy benefits escalation, in terms of the Short-term Insurance Act, 1998
(Act No. 53 of 1998). This amount will be increased on 1 April 2025 by the official CPI as published by Statistics South Africa (as defined in the Statistics Act, 1999 (Act No. 6 of 1999).
Click HERE to see a table showing the latest limit amount.

PRODUCT BASIC COVER 300 VITAL COVER PLUS SUPER COVER PLUS ABSOLUTE COVER PLUS

Gap Cover
In and out-of-hospital tariff shortfalls
The shortfall that arises after your medical aid has processed your account and is due to
service providers charging above scheme tariff for authorised procedures e.g. childbirth. 300% 700% 700% 700%
The cover is limited to a percentage of the original scheme tariff. (Subject to the shortfall
being paid from the In-Hospital or Major Medical Benefit). Out-of hospital shortfalls are
subject to a defined list of procedures. Click HERE to view.

Tariff Shortfalls for Theatre and Ward Fees, Consumables, Laparoscopic/Endoscopic

Equipment
R500 per policy R1 000 per policy R3 000 per policy R5 000 per policy
Applies to authorised in-hospital and in-lieu of hospital procedures, where the medical per annum per annum per annum per annum
aid pays a portion of the fees from its in-hospital or major medical benefit. (Includes MRI/
CT/PET scans consumables.)

Prescribed Minimum Benefits

A set of defined benefits, as per the Medical Schemes Act, in terms of which all medical schemes Covered, subject to Covered, subject to Covered, subject to Covered, subject to
have to cover the costs related to the diagnosis, treatment and care of: any emergency medical medical aid review medical aid review medical aid review medical aid review
condition; a limited set of 270 medical conditions; and 27 chronic conditions.

Shortfalls on Specialist Consultations

Cover for the shortfall on a specialist account related to the consultation in the rooms 1 consult per policy 2 consults per policy 3 consults per policy 4 consults per policy
before a member is going for an in-hospital procedure. per annum per annum per annum per annum
Limited to the following number of consults p.p.p.a (up to a max of R500 per consult)

Casualty Unit Benefit (Casualty/ER Unit linked to a hospital)

• Accidents only.
Up to R3 465 Up to R9 240 Up to R13 650 Up to R23 100
• Children under the age of 8 ONLY - May be admitted for any treatment between the per policy per annum per policy per annum per policy per annum per policy per annum
hours of 7pm to 7am from Monday to Friday, from 7pm on a Friday until 7am on a
Monday, and all day on a public holiday.

Casualty follow-up consultations 1 follow-up consultation 1 follow-up consultation 1 follow-up consultation 1 follow-up consultation
per policy per annum at per policy per annum at per policy per annum at per policy per annum at
(The initial treatment must have taken place in a casualty/ER unit linked to a hospital an ER unit an ER unit an ER unit an ER unit
following an accident.) (accident-related only) (accident-related only) (accident-related only) (accident-related only)

Emergency Medical Services (ambulance) Unlimited but subject to the

No Benefit No Benefit No Benefit aggregate annual limit per
The shortfall related to the use of Out-of-Network (Non-DSP) emergency medical services. insured person per annum

Co-Payment Benefit
In Network
• The co-payment or deductible that your medical aid charges you for certain in-hospital
procedures, e.g. a gastroscopy, colonoscopy, sigmoidoscopy or proctoscopy. Unlimited but subject
• The co-payment or deductible that your medical aid charges you for certain procedures Up to R13 650 Up to R63 000 to the aggregate annual
No Benefit
performed in the doctor’s rooms e.g. a gastroscopy, colonoscopy, sigmoidoscopy or per policy per annum per policy per annum limit per insured person
proctoscopy BUT which have been authorised and paid from the In-Hospital or Major per annum
Medical benefit.
• This co-payment or deductible is NOT related to the scheme tariff and service provider
charge shortfall or designated service provider arrangements.

Co-Payment Benefit
Out of Network i.e. Voluntary use of a non-designated service provider 2 co-payments per policy
1 co-payment per policy
• The co-payment or deductible that your medical aid charges you for certain in-hospital per annum per annum up to
No Benefit No Benefit
procedures. a combined limit of
Up to R5 250 R16 800
• This co-payment or deductible is NOT related to the scheme tariff and service provider
charge shortfall or designated service provider arrangements.

Co-Payment Benefit 2 scans per policy per

1 MRI / CT / PET scan per annum. Unlimited but
Out Of Hospital MRI / CT / PET Scans
No Benefit No Benefit policy per annum up to subject to the aggregate
The co-payment or deductible that your medical aid charges you for MRI / CT / PET scans R12 600 annual limit per insured
BUT which have been authorised and paid from the In-Hospital or Major Medical benefit. person per annum

Sub-Limit Benefit Unlimited but subject

Internal Prostheses to the aggregate annual
Up to R5 775 Up to R11 550 limit per insured person
The shortfall on a service provider account that is not covered because you have reached No Benefit
per policy per annum per policy per annum per annum.
the sub-limit for Internal Prostheses imposed by your medical aid AND which has been
authorised and paid from the In-Hospital or Major Medical benefit. Up to R68 250 per event

Sub-Limit Benefit
MRI / CT / PET Scans 1 MRI / CT / PET scan 2 MRI / CT / PET scans
The shortfall on a service provider account that is not covered because you have reached No Benefit No Benefit per policy per annum up per policy per annum up
the sub-limit for MRI / CT / PET scans imposed by your medical aid AND which has been to R3 780 to R6 300 per scan
authorised and paid from the In-Hospital or Major Medical benefit.

Sub-Limit
Up to R23 100
Colonoscopies and Gastroscopies Up to R13 650
per insured person
The shortfall on a service provider account that is not covered because you have reached No Benefit No Benefit per policy per annum.
per annum.
the sub-limit for Colonoscopies and Gastroscopies imposed by your medical aid AND Up to R3 780 per event
Up to R6 300 per event
which has been authorised and paid from the In-Hospital or Major Medical benefit.

Dental Benefit
The shortfall that arises after your medical aid has processed your account and is due
to service providers charging above scheme tariff for authorised dental procedures Unlimited but subject Unlimited but subject Unlimited but subject Unlimited but subject
performed in hospital or in doctor’s rooms and paid from the in-hospital or major medical to the aggregate annual to the aggregate annual to the aggregate annual to the aggregate annual
benefit only. The cover is limited to a percentage of the original scheme tariff, as follows: limit per insured person limit per insured person limit per insured person limit per insured person
• Adults and dependants over 18 years of age: Treatment of impacted wisdom teeth, per annum per annum per annum per annum
extractions, apicectomies or loss of teeth due to oncology or trauma ONLY.
• Dependants up to 18 years of age: Any procedure or treatment.
 PRODUCT BASIC COVER 300 VITAL COVER PLUS SUPER COVER PLUS ABSOLUTE COVER PLUS

Global Fee Benefit

Where a global fee has been negotiated between a medical aid and service providers Up to R12 600 Up to R25 200
for a specific procedure e.g. robotic surgery (which includes ALL costs related to that No Benefit No Benefit
per policy per annum per policy per annum
procedure) and service providers charge amounts in excess of this global fee (not related
to a tariff rate, co-payment or sub-limit).

Oncology Gap Benefit

The shortfall that arises after your medical aid has processed your account and is due Unlimited but subject Unlimited but subject Unlimited but subject Unlimited but subject
to service providers charging above scheme tariff for medical aid approved oncology to the aggregate annual to the aggregate annual to the aggregate annual to the aggregate annual
treatment plans. limit per insured person limit per insured person limit per insured person limit per insured person
(NB: Subject to the gap cover percentage; and medical aid approved treatment plan per annum per annum per annum per annum
being covered up to scheme tariff and within annual scheme oncology limit).

Oncology Co-Payment Benefit:

In Network
• The co-payment or deductible that your medical aid charges you for certain in-hospital Unlimited but subject
procedures. This co-payment is NOT related to the scheme tariff and service provider Up to R13 650 Up to R63 000 to the aggregate annual
No Benefit
charge shortfall or designated service provider arrangements. per policy per annum per policy per annum limit per insured person
• For claims where the medical aid will only pay a percentage for the approved treatment per annum
and the policyholder needs to pay the remaining percentage of the account.
• All costs to be within the annual scheme oncology limit.

Oncology Co-Payment Benefit:

Out of Network i.e. voluntary use of a non-designated service provider
• The co-payment or deductible that your medical aid charges you for certain in-hospital 2 co-payments per
1 co-payment per policy
procedures. This co-payment is NOT related to the scheme tariff and service provider policy per annum up
No Benefit No Benefit per annum.
charge shortfall or designated service provider arrangements. to a combined limit of
Up to R5 250 R16 800
• For claims where the medical aid will only pay a percentage for the approved treatment
and the policyholder needs to pay the remaining percentage of the account.
• All costs to be within the annual scheme oncology limit.

Oncology Extender Benefit: Unlimited but subject

Up to R36 750 to the aggregate annual
Includes ANY approved costs above annual scheme oncology limit but subject to the No Benefit No Benefit
per policy per annum limit per insured person
medical aid scheme covering up to this limit. per annum

Oncology “New-Tech” Benefit

We cover the shortfall / co-payment on new technology oncology treatment (specifically Up to R8 610 Up to R17 325
No Benefit No Benefit
Keytruda®,Xalkori®, Tagrisso®, Yervoy®, Zelboraf®, Imbruvica®). Subject to a medical aid per policy per annum per policy per annum
authorised treatment plan and designated service providers being utilised.

Oncology Gap Benefit:

Breast Reconstruction Surgery
The shortfall that arises after your medical aid has processed your account and is due Up to R18 900 Up to R36 750
to service providers charging above scheme tariff for medical aid approved oncology No Benefit No Benefit per beneficiary per life per beneficiary per life
related breast reconstruction surgery, including the unaffected breast. (NB: Subject to of the policy of the policy
the gap cover percentage; and medical aid approved treatment plan being covered up
to scheme tariff and within the annual scheme oncology limit).

Maternity Follow-Up Consultations Up to R700 per Up to R1 250 per

Cover for the shortfall on a specialist (OBGYN/Paediatrician) account related to a No Benefit No Benefit consultation per policy consultation per policy
consultation in the rooms within 6 weeks after childbirth per annum per annum

Limited to a maximum of Limited to a maximum of

Private Ward Benefit For Childbirth: No Benefit No Benefit R525 per day, for a total R2 100 per day, for a total
The shortfall between the General Ward Rate and the Private of 3 consecutive days of 3 consecutive days
Ward Rate for hospitalisation where an admission to a Private
Ward occurred. Limited to a maximum of Limited to a maximum of
For Non-Childbirth: No Benefit No Benefit R525 per day, for a total R2100 per day, for a total
of 3 consecutive days of 3 consecutive days

THE FOLLOWING BENEFITS ARE NOT SUBJECT TO THE AGGREGATE ANNUAL LIMIT
PRODUCT BASIC COVER 300 VITAL COVER PLUS SUPER COVER PLUS ABSOLUTE COVER PLUS

Insured / Spouse: R7 350 R10 500 R21 000 R31 500

Accidental Death Cover
A lump sum payout for death due to an accident.
Dependant: R4 200 R5 775 R8 400 R21 000

Policy Extender
The full gap cover premium is covered in the case of the accidental death of the main 12 months 12 months 12 months 12 months
policyholder.

Medical Aid Contribution Waiver

Provides cover towards a policyholder’s medical aid contribution in the case of the 6 months. Up to a max. 6 months. Up to a max. 6 months. Up to a max.
No Benefit
accidental death of the main policyholder. Cover is limited to the lower of the actual of R4 620 per month of R5 775 per month of R6 930 per month
medical aid contribution or the maximum amount allowed.

TRA ASSIST (powered by MobiMed) BASIC COVER 300 VITAL COVER PLUS SUPER COVER PLUS ABSOLUTE COVER PLUS

6 trips per policy 6 trips per policy 6 trips per policy 6 trips per policy
Home Drive
per annum. Limited to a per annum. Limited to a per annum. Limited to a per annum. Limited to a
A designated driver service including “Own Vehicle” OR “Uber” services. 50km radius. 50km radius. 50km radius. 50km radius.

Panic Button
24-hour access to a crisis manager who will guide you through an emergency.
Included Included Included Included
Includes Roadguard: A security assistance service offered to clients that might find
themselves next to the road due to a breakdown.

Medical Health and Trauma Counselling Line

Unlimited access to qualified nurses 24 hours a day for telephonic emergency medical
Included Included Included Included
advice, assessment of symptoms, explanation of medical terms, etc.
Includes a COVID-19 CARE LINE.

Submit Claim
Included Included Included Included
Submit your claims documents via the mobile app.

TRAVEL BENEFIT
All TRA Gap Cover policyholders, under the age of 71, have access to the benefit of comprehensive travel insurance, the cost of which is covered by TRA provided that you remain a TRA Gap Cover
policyholder and ensure that premium payments thereunder are up to date. The said travel insurance is underwritten by Guardrisk Insurance Company Limited, a licensed non-life insurer, and administered
by Hepstar Financial Services (Pty) Ltd, both being registered Financial Services Providers. Click HERE for full details. Should you plan to travel and have any enquiries about the cover or wish to request the
documentation confirming cover, please contact Hepstar Financial Services (Pty) Ltd on +27 (0)86 144 4548 or email [email protected].
You also qualify to buy a top-up plan by clicking HERE to increase your medical and baggage related cover, as well as add cover for trip cancellation, pre-existing medical conditions, missed connections and more.
 BASIC COVER 300 VITAL COVER PLUS SUPER COVER PLUS ABSOLUTE COVER PLUS
Benefits include but are not limited to:

Emergency Medical and Related expenses R1 000 000

Medical Evacuation, Repatriation, or Transportation to a Medical Centre Actual expense covered when arranged by Hepstar Financial Services

Personal Accident Cover Death: R25 000 / Permanent Disability: up to R25 000

Theft or Accidental Damage during trip R 5 000 / Single item limit: R 1 500

Theft, Damage or loss by Airline R5 000 / Single item limit: R 1 500

Baggage Delay (more than 4 hours) R500

Baggage Delay (more than 24 hours) R1 000

MONTHLY PREMIUMS
PRODUCT BASIC COVER 300 VITAL COVER PLUS SUPER COVER PLUS ABSOLUTE COVER PLUS

Under 65’s premium per policy per month

(Based on the age of the oldest Beneficiary)
R360 R380 R620

Premium per Individual per policy per month R 99

Premium per Family per policy per month R180

Over 65’s premium per policy per month

(Based on the age of the oldest Beneficiary)
R360 R540 R570 R770

GAP COVER
The Important Information

All of our 2025 Gap Cover Policies:

Provide benefits for a policyholder and their spouse and those financially May allow for immediate benefits for all policyholders except for a limited list
dependent on them (child/children and/or aged parents) who are covered on of specific conditions and/or procedures (there is no general 3 month waiting
one policy of a registered medical aid scheme. Subject to proof of membership period).
and the premium being based on the age of the oldest beneficiary. Members
and their dependants can also be on two different medical aids and one Gap Cover Prescribed Minimum Benefits (PMB’s) where a medical aid scheme has
Cover Policy but only if they are legally married, or common law partners failed to meet its obligations in this regard (Subject to medical aid scheme
verified by submission of an affidavit confirming 12 months of cohabitation. review and for non-emergencies only).

Have no entry age limit. Are not medical aid schemes. The cover is not the same as that of a medical aid
scheme. The cover is not a substitute for a medical aid scheme membership.

NB: Refer to the policy document for the complete list of terms and conditions.

WHEN CAN YOU CLAIM?

We have payment runs three times a week, making us well known for our great claims turnaround time!

General Waiting Period • Oesophagitis, Gastroenteritis and Gastro-Intestinal Disorders

There is no general three (3) month waiting period. The following waiting periods • Male genital system (including prostatectomy)
commence from the Join Date of the Gap Cover Policy: • Carpal Tunnel Syndrome
• Any Ear, Nose and Throat procedures (including nasal, sinus, tonsil and adenoid
10 Month Condition Specific Waiting Period procedures)
No claims may be submitted within the first 10 months of membership for any • Diabetes and related complications
Gap Cover policy if they relate to any of the following conditions: • Respiratory conditions e.g. COPD; Cystic Fibrosis (excluding viral conditions
• Head, neck and spinal procedures e.g. Laminectomy e.g. bronchitis)
• All types of hernia procedures
All claims for these conditions received within the waiting period will be reviewed
• Endoscopic procedures e.g. Colonoscopy, Gastroscopy
by medical management to identify pre-existing conditions.
• Pregnancy and childbirth (including caesarean delivery)
• Gynaecological conditions e.g. Hysterectomy Cancer Diagnosis Waiting Period
• Joint replacement (including Arthroplasty, Arthroscopy, Metatarsal Osteotomy) If a Policyholder is diagnosed with any form of cancer prior to membership, all
but excluding treatment due to accidental trauma related claims will be subject to a nine (9) month waiting period. If a Policyholder
• Inability to walk / move without pain has previously been diagnosed with cancer and is currently in remission, the
• Any renal, liver, kidney and bladder conditions Policyholder needs to advise the insurer by way of medical evidence that the
• Cardiac (relating to the heart) remission period has been for two (2) or more consecutive years.
• Dentistry (unless due to accidental trauma or oncology)
• Cataracts and / or eye laser surgery (including all eye and lens procedures)
Pre-Existing Medical Condition/s Waiting Period
• Neurological conditions and procedures NO claims relating to any pre-existing condition/s that may lead to hospitalisation
(excluding cancer: see above) will be covered within the first six (6) months of
• Organ transplants (including cochlear implants)
membership. The insurer reserves the right to request any clinical information
• Reconstructive surgery as a result of an incident or condition that occurred from a Policyholder’s doctor should a claim in this period indicate, and/or relate
prior to membership (including skin grafts) to, a pre-existing condition. All claims for these conditions received within the
• Mental health or psychiatric conditions (including depression) waiting period will be reviewed by medical management to identify pre-existing
• Varicose veins conditions.

Errors and Omissions Excepted I Terms and Conditions apply I This infographic does not constitute advice I
Consult your intermediary for advice regarding product choice I The products reflected above are not medical aid
schemes I They are not the same as medical aid schemes I They are not substitutes for medical aid schemes | TRA
(Total Risk Administrators Pty Ltd) is an authorised financial services provider - FSP No 40815 Underwritten by: Auto&General Insurance Company Limited
A licensed non-life Insurer & Financial Services Provider - Reg No 1973/016880/06