Health - A-Z Medical Gap Cover Glossary

Accident

Bodily injury caused by violent accidental and external physical means.

 

Eligible child

A child, including a legally adopted child or stepchild, of a principal insured person who is an eligible dependent child on the principal insured persons medical scheme and who is not already insured.

 

As soon as such child ceases to satisfy the conditions above, such child will no longer be an eligible child and will therefore no longer be covered under the Policy.

 

Eligible spouse

The spouse of the principal insured person and who is registered as an adult dependant on the principal insured persons medical scheme and who is not already insured under similar cover

Should a principal insured person have more than one spouse who could qualify as an eligible spouse, then that principal insured person must make an irrevocable nomination of one eligible spouse to whom the benefits provided by this policy are to apply.

 

Eligible extended dependant

The parent or sibling on the principal insured person and who is registered as an extended adult dependant on the principal insured persons medical scheme and who is not already insured under similar cover.

 

Family

The principal insured person, the eligible spouse provided such spouse is an insured person but not a principal insured person, the eligible children provided they are insured persons and the eligible extended dependants provided they are insured persons.

 

Hospital

Any institution in the territory of RSA and overseas which in the opinion of the Company meets each of the following criteria:

  • Has a diagnostic and therapeutic facility for surgical and medical diagnosis treatment and care of insured and sick persons by or under the supervision of a staff of medical practitioners.
  • Provides nursing service supervised by registered nurses or nurses with equivalent qualifications.
  • Is not other than incidentally either a mental institution or a convalescent home.
  • Is not a place of rest for the aged or a place for drug addicts or alcoholics or a health hydro or natural cure clinic or similar establishment.
  • Is not an institution providing long-term care for the blind deaf dumb or other handicapped persons.

 

Illness

Any one somatic illness or disease which manifests itself during the period of insurance and includes premature senile degenerative changes, but not an illness which is of such a nature as to be incapable of diagnosis by objective evidence or which though capable of diagnosis by such evidence has not been so diagnosed.

 

Incident

Any one accident or illness that causes an insured person to be confined to hospital and to undergo certain medical or surgical procedures and/or operations.

 

Insured person

A principal insured person or an eligible spouse of a principal insured person (if spouse’s cover has been granted) or an eligible child of a principal insured person (if dependant’s cover has been granted) or an eligible extended dependant (if dependant’s cover has been granted). It is a pre-requisite for an Insured Person to be and remain a member or dependant of a registered medical scheme at all times during the currency of the policy and who is accepted by the Company as eligible for participation in the insurance provided by this policy.

 

Medical Scheme

A Medical scheme registered by the Registrar of Medical Schemes in terms of the Medical Schemes Act no 131 of 1998 in terms of which a contribution is paid for on a monthly basis which, based on a set of rules, provides you with insurance against expenses incurred in the event of illness or injury.

 

Medical and surgical procedures and/or operations

Any procedure listed in the GAP provider Tariff list.

 

Medical practitioner

A legally qualified registered medical practitioner registered with the South African Medical and Dental Council

 

Treatment

Any form of investigation or examination by or consultation with or treatment by a medical practitioner for the purpose of treating or monitoring an insured person’s medical condition arising out of an insured incident.

 

Tariff

The tariff table published by the GAP provider made up of procedure codes as previously published by the Council for Medical Schemes and appropriate tariffs as determined by the GAP provider for each procedure code.

 

Hospital Confinement

Admission to a hospital ward, limited to General Ward, Maternity Wards, Private Wards and Special Care Units

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