Absa Gold Gap Cover

What is Gap Cover?

Gap Cover is a short term insurance policy that is designed to cover the gap between what your medical scheme pays to a
specialist and anaesthetist performing a procedure in-hospital and the actual amount charged, up to a maximum of 500% of
the medical scheme’s rate (MSR).

Gap Cover specifically covers the shortfall for in-hospital services, and excludes shortfalls for day-to-day expenses.

Below are actual examples of Gap Cover claims where members would have had to pay these co-payments out of pocket if
they did not have GAP cover:

Gynaecologist 100% MSR Gap Cover paid

Child birth R10 525.18 R4 947.40 R6 677.78

Surgeon charged 100% MSR Gap Cover paid

Knee replacement R33 552.61 R13 212.10 R20 340.51

Who may join Gap Cover?

Cover is available to all Aurecon employees under the age of 70 who is covered on a registered SA medical scheme.

Who in your immediate family will be covered?

Your spouse, common law spouse and natural-, adopted; and/or foster children under the age of 21 will be covered. This age
may be extended to 25 in respect of an unmarried child who is a full-time student. No other dependents (i.e. mother & father
of insured/spouse) will be covered under your policy. Cover is available to all members under the age of 70 who is covered on
a registered SA medical scheme.

Exclusions
Gap Cover will not cover co-payments for dental implants, mental depression and stress related conditions, suicide and/or death
due to self-inflicted injuries, drug and/or alcohol abuse and criminal activity and war, etc. Kindly refer to the general exceptions
in your policy document for detailed information.

Benefits for Oncology Treatment and Biological Cancer drugs are excluded for any individual who had been diagnosed with
cancer prior to date of inception. This is a lifelong exclusion, whether the cancer is being treated at date of inception or in
remission.

Premium
Absa Gold : R155 per membership per month

Please note that the Gap Cover contribution will be deducted from your bank account via debit order through Ambledown who
is the administrator for Absa Gap Cover.

Contributions are paid in advance and no backdated applications will be allowed.

Underwriting
Gap Cover is offered on a voluntary basis and therefore individual underwriting will apply. This implies the following:

• Three month general waiting period

• Twelve month exclusion on any existing condition

However a concession was made for Aurecon members joining from 1 December 2016
to 31 January 2017 to join without underwriting implications.

Summary of Absa Gold Gap Cover

• Provides top-up cover for in-hospital specialist and anaesthetist bills that are short-paid by the medical scheme
• Covers up to five times the medical scheme tariff, limited to R1 000 000 per family per annum
• Cover for Priority plan deductibles and co-payments on Scopes, MRI & CT scans; benefits for co-payments or
deductibles are limited to R30 000 per insured person per annum or R50 000 per family per annum
• Top-up for benefits that have sub-limitations imposed by the medical scheme for in-hospital admissions; benefits for
charges above any sub limitations (other than biological cancer drugs) are limited to R10 000 per principal insured
per annum
• Oncology (cancer) treatment where cost is incurred after R200 000:
• Oncology treatment: 20% of expenses can be claimed from Gap Cover up to a maximum of R200 000
• Biological cancer drugs: out-of-pocket expenses can be claimed from Gap Cover up to the maximum of
R100 000

Application Process

Please complete the attached application and submit this to absahealthcare.gap@absa.co.za.

Please ensure that you complete your work e-mail address on the application in order to ensure that you will be linked to the
correct employer group and qualify for the reduced group rates.

Claims Process

Claims have to be submitted within 180 days of treatment date.

Please note that due to confidentiality the completed claim form should be submitted directly to
claims@ambledown.co.za. Please ensure that you also attach a copy of the supporting accounts as well as the claims advice
from the medical scheme highlighting the treatment for which a shortfall in payment by the scheme has occurred.

Claims queries can be directed to 0861 262 533

Should you require further information on Gap Cover Insurance, please contact Absa Consultants & Actuaries - Health Care
helpdesk on 0860 100 380 or absahealthcare.gap@absa.co.za

The newsletter is a summary and does not supersede the Policy. In the event of any discrepancy between this newsletter and
the Policy, the Policy will prevail.
Disclaimer
Although this document has been prepared with due care and in good faith, the interpretations and opinions are those of the authors and
are subject to change without notice. As such, the contents do not constitute definitive advice and should not be accepted as such.
Neither Absa Consultants and Actuaries (Pty) Limited nor the authors accept liability for any damage whatsoever or however it may arise,
including but not limited to, direct, indirect or consequential loss that may arise as a result of sole reliance on the information herein.
Competent professional advice should be sought when dealing with any contentious issue. Absa Consultants and Actuaries is a duly
authorised financial services provider.