Benefit increase:
Benefit increases should correlate to the premium increases. In other words, if your premiums go up by 10%, so should your benefits. If the benefits increase by less than your premium, then your increase is actually higher than reported.
We work out the sublimits of your premiums, and calculate the difference between 2017 and 2018.
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Co-payment increase:
We work these out similarly to the Benefit increase, above.
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Note: Unfortunately, we do not have access to see whether the scheme tariffs have increased, and by how much. Without this information, it is impossible to accurately work out how your 2018 benefits compare to 2017 benefits.
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The post Kaelo Xelus Gap Cover – Sign Up appeared first on Medical Aid Bible.

1. During the first 3 (three) months of membership, a general waiting period, as defined herein, shall apply.

2. During the first 12 (twelve) months of membership, a condition-specific waiting period, as defined herein, shall apply.

3. Waiting periods shall be applied to the cover of the relevant insured person, from the time that such insured’s cover commences under this policy.

4. In the event that an Insured under this policy previously had a Medical Expense Shortfall Policy, as defined, the period of the condition-specific waiting period above shall be reduced by the expired portion of the condition-specific waiting period served under such previous policy.

5. In the event that there is no unexpired portion of the condition-specific waiting period of such previous policy, the condition-specific waiting period of this policy will be waived. Such waiver only applies if the break in cover between the two policies is 90 (ninety) days or less.

6. Xelus reserves the right to waive the Waiting Periods for the Eligible Members of Participating Employers based upon pre-determined criteria. Any such waiver applied will be indicated on the policyschedule of the Insured Member.

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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:

1. Any Treatment or Medical Procedure related to obesity.

2. 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.

3. Suicide, attempted suicide or wilful injury to oneself.

4. Abortion, attempted abortion or any complications related thereto unless treatment is, in the sole opinion of Xelus, of a non-elective nature.

5. Any procedure or examination where there is no objective indication of impairment in normal health.

6. 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.

7. The failure of an Insured to follow any medical advice given by a Medical Practitioner.

8. 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.

9. 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.

10.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.

11. Participation or attempted participation by any Insured Person in any of the following:
11.1. Defence force, police force, medical rescue service, firefighting service, correctional services facility or the disarming of explosives;
11.2. 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);
11.3. Hazardous sport (amateur or professional) as defined;
11.4. Form of race or speed test (other than on foot or involving any non-mechanically propelled vehicle, vessel, craft or aircraft).

12. Riots, wars, political acts, public disorder or any acts or attempted acts of any of the following:
12.1. 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;
12.2. War, invasion, act of foreign enemy, hostilities, civil war or warlike operations (regardless of whether war is declared or not);
12.3. 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;
12.4. 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;
12.5. 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;
12.6. 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;
12.7. 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.

13. Any claim that is excluded or rejected by the Eligible member’s medical scheme.

14. 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.

15. The following procedures, items, services, service providers or events:
15.1. External prosthesis;
15.2. Any appliances including, but not limited to, wheelchairs, beds or convalescing equipment;
15.3. 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);
15.4. Harvesting and/or preserving of human tissues, including but not limited to stem cell regeneration;
15.5. Breast augmentation;
15.6. Gastroplasty, lipectomy or otoplasty;
15.7. Gender reversal procedures;
15.8. Therapeutic massage therapists;
15.9. Rehabilitation, frail care or hospice services;
15.10. Step-down facilities;
15.11. TTO (to-take-out) medicines;

16. 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.

17. 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.

18. 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.

19. Any Penalty, as defined in this policy document, applied by the Eligible Member’s medical scheme.

20. 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.

21. 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;

22. Any treatment or Medical Procedure for infertility.

23. 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.

24. Any act by an Insured that wilfully exposed the Insured to danger (except where such act was necessitated in order to save human life).

25. 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.

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The post Kaelo Xelus gap Cover – Policy Document appeared first on Medical Aid Bible.

Kaelo Xelus offers a gap cover product that we feel has excellent benefits and is well priced. Please read “How gap covers work” if you re unfamiliar with gap products.
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The benefits of this gap product are included per each 2018 plan that we show on this website, so you can immediately see the full benefit of the medical aid ad the gap. Simply find your plan using our menu above, and see how this gap’s benefit fit in.
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Cost

Family: R240pm (2017)
If a member is 65yrs+: R400pm (2017)
Download application
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Shortfall benefit

• Kaelo Xelus will pay an additional 500% of the medical aid rate, covering shortfalls for all service providers like surgeons, radiologists, pathologists and physiotherapists for services rendered in a hospital, day clinic or where a medical aid pays for treatment in a specialist’s rooms out of risk (not out of savings).

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Oncology treatment benefit

• An additional 500% of medical aid rate to cover shortfall for oncologists, biological medication, chemotherapy, radiotherapy, radiology, specialised scans and pathology.
• Full cover for the 20% co-payment for oncology services imposed by some medical aids.
• Where a medical aid imposes an overall annual limit on oncology treatment, this gap cover will pay for full cover thereafter.

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Co-payment and Deductible benefit

• Full cover for all upfront co-payments (fixed Rand amount).
• Cover of up to R12,000 once a year if you use a non-network hospital and have to pay a fixed Rand amount as a penalty.

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Sublimit Enhancer

• Where a medical aid imposes a Rand limit on a benefit, there is an additional R40,000 per event (unlimited events per year). This usually applies to internal prosthetic devices, in-patient dentistry or specialised radiology.

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Casualty/ER Benefit

• Covers costs not paid directly by medical aid for emergency treatment at a hospital casualty ward, up to R12,000 per event. These costs are covered even if the medical aid pays them out of your savings.

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Benefit Extenders

• Family Booster Benefit: For a premature birth, more than 6 weeks before the due date, a R12,000 lump sum payment.
• Hospital Booster Benefit: You get a cash payout for each day spent in hospital as a result of accident or premature birth:
  • Day 1-13: R300 per day
  • Day 14-20: R600 per day
  • Day 21-30: R1,200 per day
• Family Protector Benefit: A R12,000 payment on death or permanent disability. If the causue was accidental, the benefit doubles to R24,000.
• Dental Reconstruction Benefit: If required as a result of trauma or oncology treatment, all related costs up to R40,000 per event will be covered. This benefit only applies to events occurring after commencement of cover.
• Contribution Waiver Benefit: If the principal member of the medical aid passes away or becomes permanently disabled, the medical aid contribution will be covered for 6 months up to R4,400 per month. The gap policy premium will also be waived for the 6 months.
• Road Accident Fund Benefit: In the event of injury in a vehicle accident where the policy holder was not at fault, RoadCover will provide all legal assistance needed to finalise the claim. The entire award from RAF will be paid out. All legal costs are covered.

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The small print

Read the full policy document here
Read the exclusions here
Read about Waiting Periods
Read about what procedures are covered
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