Kaelo Xelus Gap Cover – Exclusions

All gap covers have extensive exclusions, with which you should familiarise yourself. Kaelo’s are listed below. You can also view the full policy document here, or read about the waiting periods.

Xelus or the Underwriter shall not be liable for any claim caused by or related to, whether such cause or related cause is as a direct or indirect consequence of any of the following:

  • Any Treatment or Medical Procedure related to obesity.
  • Cosmetic surgery except in the case where reconstructive cosmetic surgery is necessitated, in the sole opinion of Xelus, as a direct result of Trauma or other essential non-elective Treatment or Medical Procedure.
  • Suicide, attempted suicide or wilful injury to oneself.
  • Abortion, attempted abortion or any complications related thereto unless treatment is, in the sole opinion of Xelus, of a non-elective nature.
  • Any procedure or examination where there is no objective indication of impairment in normal health.
  • The consumption of any drug or narcotic, whether legal or illegal, unless legally prescribed by and taken in accordance with the instructions of a Medical Practitioner.
  • The failure of an Insured to follow any medical advice given by a Medical Practitioner.
  • Any incident, Illness, Accidental Harm or event directly or indirectly caused by the continuous and excessive consumption of alcohol or where the insured suffers from alcoholism.
  • Any incident, Illness, Accidental Harm or event directly or indirectly attributable to the member having a blood alcohol content exceeding thirty milligrams per one hundred millilitres of blood.
  • Nuclear weapons, nuclear material, ionising radiations or contamination by radioactivity from any nuclear fuel, or from any nuclear waste, or from the combustion of nuclear fuel which includes any self-sustaining process of nuclear fission.
  • Participation or attempted participation by any Insured Person in any of the following:
    • Defence force, police force, medical rescue service, firefighting service, correctional services facility or the disarming of explosives;
    • Aviation activities where any medicalexpense incurred in relation to such activities are insured by any other party (excludes fare-paying passengers in a licensed passenger carrying aircraft);
    • Hazardous sport (amateur or professional) as defined;
    • Form of race or speed test (other than on foot or involving any non-mechanically propelled vehicle, vessel, craft or aircraft).
  • Riots, wars, political acts, public disorder or any acts or attempted acts of any of the following:
    • Civil commotion, labour disturbances, riot, strike, lock-out or public disorder or any act or activity which is calculated or directed to bring about any of the above;
    • War, invasion, act of foreign enemy, hostilities, civil war or warlike operations (regardless of whether war is declared or not);
    • Mutiny, military rising or usurped power, martial law or state of siege, or any other event or cause which determines the proclamation or maintenance of martial law or state of siege, insurrection, rebellion or revolution;
    • Any act (whether on behalf of an organisation, body, person or group of persons) calculated or directed to overthrow or influence any state or government or any provincial, local or tribal authority with force or by means of fear, terrorism or violence;
    • Any act calculated or directed to bring about loss or damage to further any political aim, objective or cause, or to bring about any social or economic change, or in protest against any state or government, or any provincial, local or tribal authority, or for the purpose of inspiring fear in the public, or any section thereof;
    • Terrorism. An act of terrorism means the use or threat of violence for political, religious, personal or ideological reasons. This may or may not include an act that is harmful to human life. It could be committed by any person or group of persons, acting alone, on behalf of or with any organisation or government. It includes any act
      committed with the intention to influence any government or inspire fear in the public;
    • The act of any lawfully established authority in controlling, preventing, suppressing or in anyother way dealing with any event referred to in any of clauses 12.1 to 12.6 above.
  • Any claim that is excluded or rejected by the Eligible member’s medical scheme.
  • Any claim that does not form part of the registered benefits of the Eligible member’s medical scheme but has been paid on an ex-gratia basis.
  • The following procedures, items, services, service providers or events:
    • External prosthesis;
    • Any appliances including, but not limited to, wheelchairs, beds or convalescing equipment;
    • All dental procedures including, but not limited to, crowns, bridges, dental implant related procedures, orthognathic surgery, temporo-mandibular joint (“TMJ”) surgery, labial frenectomy, bone augmentations, bone or tissue regeneration. The above definition does not include basic dentistry, as defined in Section A.4 of this Policy);
    • Harvesting and/or preserving of human tissues, including but not limited to stem cell regeneration;
    • Breast augmentation;
    • Gastroplasty, lipectomy or otoplasty;
    • Gender reversal procedures;
    • Therapeutic massage therapists;
    • Rehabilitation, frail care or hospice services;
    • Step-down facilities;
    • TTO (to-take-out) medicines;
  • Any expenses incurred as a result of an injury in a motor vehicle accident that are subsequently recoverable by the relevant Insured Person from the Road Accident Fund.
  • Any expenses incurred as a result of an injury on duty that are subsequently recoverable by the relevant
    Insured Person from the Workmans Compensation Fund.
  • Any co-payment or deductible applied by the Eligible Member’s medical scheme against the benefits to be
    received or paid out from the medical scheme, other than those specifically listed in the Benefit Schedule
    outlined in Section F.
  • Any Penalty, as defined in this policy document, applied by the Eligible Member’s medical scheme.
  • Any fee charged by a Medical Practitioner, Hospital or other medical service provider that constitutes Split Billing as defined in Section A of this policy. This exclusion does not apply to Balance Billing, also defined in Section A of this policy.
  • Any criminal act or attempted criminal act by an Insured which shall include the submission of any fraudulent information or the use of any fraudulent means to obtain any benefit under this Policy;
  • Any treatment or Medical Procedure for infertility.
  • Expenses incurred for transport charges or for services rendered whilst being transported in any vehicle, vessel or craft whether or not such vehicle, vessel or craft is specifically designed for the purposes of medical emergency transport.
  • Any act by an Insured that wilfully exposed the Insured to danger (except where such act was necessitated in order to save human life).
  • Any Treatment or Medical Procedure that, in the sole opinion of Xelus, is of such a nature that it is not considered to be medically necessary, or where alternative conservative treatment would provide a similar outcome, or is of such a nature that there is no likely improvement in the medical condition of the insured patient.
    Xelus reserves the right to amend the above Policy Exclusions from time to time.
Another worthwhile read:
Fusion Gap Cover - 2018 Benefits and Premiums

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