醫療綜合附加險 Ultimate Gap Cover
在南非華人當中保險意識提升,而有許多人購買醫療保險。當有事故或疾病住院後,一個常見的問題是:為什麼住院費用保險公司沒有全額給付?其中一項原因是專科醫生收費較醫療保險公司標準費用高，並且有些疾病,保險公司會依據規定收取自負額。
医疗保险针对住院时医生费用不全额给付
案例一: 一位太太於三年前在約堡一家私立醫院做一項婦科手術。醫院收費R12,000, 婦科醫生收費R13,000,麻醉師費用R3,000。她全家醫療保險選項為Discovery
Classic Core。醫院費用Discovery全額給付,
而婦科醫生費用理賠R6,500,麻醉師費用理賠R1,000。客戶最後自己付了R6,500加R2,000, 總共R8,500。
案例二: 李太太購買了Discovery Claissic Core 在7個月前帶小孩子去醫院住院進行牙科治療，在此期間醫院以及醫生費用保險公司都按照保險公司定價給予賠付，但是依據保險公司規定，此項治療在入院時需客戶自行承擔R3,300的自負額，保險公司不予索賠。 Discovery Classic Core選項為住院險,住院時給付至200%,也就是保險公司標準費用的兩倍。此選項是Discovery住院險險種中最好的。然而由於醫生及麻醉師的費用高昂,甚至超過標準費用的兩倍,或者針對於特殊檢查或者特殊專科治療所需要的自付額，因此超過的部分要由客戶自行承擔。 |
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Sirago医疗综合附加险 |
有鑑於此,我們建議您購買Sirago醫療綜合附加險(Ultimate Gap Cover),配搭您現有的醫療保險。只要每月R376的保費,全家即可享有住院時額外500%的保障，每年不超過三次每次不超過R15,000的自付額索賠保障,專科醫生門診索賠福利保障以及癌症索賠福利。
Sirago Ultimate Gap Cover醫療綜合附加險所提供的方案條款如下: 保費：單身R335,家庭R376每月 沒有最高投保年齡 – 任何年齡皆可投保 包含住院眼科和牙科 包含麻醉師，婦產科，放射線科，病理學（驗血），其他專科醫生 家庭選項含蓋所有醫保陪伴受保人。 可以跟任何醫保公司選項配搭 索賠直接付進投保人帳戶 標準三個月等候期(waiting period),即投保後三個月內不能索賠, 已有疾病(pre-existing conditions)包括懷孕有12個月的等候期。 |
附加险福利 |
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福利 BENEFITS |
顶尖 ULTIMATE GAP COVER |
优良 PLUS GAP COVER |
普通 GAP COVER |
住院医生费用差额 Gap Cover |
500% Subject to OAL |
Up to 500%, maximum of 600% Subject to OAL |
Up to 500%, maximum of 600% Subject to OAL |
特定项目定额自付额 Co-Pay Cover |
Limited to the OAL; maximum R16,000 per claim |
Limited to the OAL; maximum R13,000 per claim |
R40,000 sub-limit; maximum R10,000 per claim |
入院费 Admission Fee Cover |
Limited to R,500 per admission |
Limited to R3,500 per admission |
Limited to R3,000 per admission |
非指定医院罚金 Penalty Fee Cover |
R9,500 per claim, a maximum of 2 claims per policy per annum. |
R5,500 per claim, maximum of 2 claims per policy per annum. |
No benefit |
医生诊所治疗或手术 Day Hospital/Clinic or In-room Surgical Procedures Cover |
Settle the Gap portion |
Settle the Gap portion |
Settle the Gap portion |
Primary Care Consultation Benefits |
R3,500 sub-limit per policy per annum. GP claims x 3 with R325 limit per consult. Dental claims x 3 with R350 limit per consult. Alternative therapy x 3 with R450 per consult. Applicable to Gap portion only; bios, physios, chiros and OT |
No benefit |
No benefit |
Emergency Room Cover |
R11,000 sub-limit. Accident and trauma R8,500 stated benfit. Illness treatment R2,500, Gap portion only. |
R6,500 sub-limit. Accident and trauma R4,500 stated benfit. Illness treatment R2,000, Gap portion only. |
R4,000 sub-limit. Accident and trauma R2,000 stated benfit. Illness treatment R2,000, Gap portion only. |
PMB Cover |
Subject to OAL, for the use of non-DSP facilities |
Subject to OAL, for the use of non-DSP facilities |
R30,000 per claim, for the use of non-DSP facilities |
Cancer Benefit |
R450,000 limit per policy once medical scheme oncology benefit has been reached and a percentage co-payment is applied. |
R300,000 limit per policy once medical scheme oncology benefit has been reached and a percentage co-payment is applied. |
R100,000 limit per policy once medical scheme oncology benefit has been reached and a percentage co-payment is applied. |
Cancer Boost |
R100,000 per beneficiary, restricted to medical scheme options with Rand value limit for cancer cover. |
R50,000 per beneficiary, restricted to medical scheme options with Rand value limit for cancer cover. |
No benefit |
Day to Day Specialist Consultation Fee |
R6,500 sub-limit. R1,350 per claim, 3 x per beneficiary, Gap portion only |
R4,000 sub-limit. R825 per claim, 3 x per beneficiary, Gap portion only |
No benefit |
Hospital Account Shortfalls |
R5,000 sub-limit per policy. Maximum R1,250 per claim, 3x per beneficiary. |
R3,000 sub-limit per policy. Maximum R750 per claim, 3x per beneficiary. |
R1,500 sub-limit per policy. Maximum R500 per claim, 3x per beneficiary. |
Preventative Care Cover |
R8,000 sub-limit. R1,200 per claim, x3 per beneficiary per annum: pap smear, cholesterol, blood glucose, flu vaccination, childhood immunisation, bone density scan, prostate specific antigen, mammogram, contraceptive device implantation |
R3,600 sub-limit. R1,000 per claim, x3 per beneficiary per annum: pap smear, cholesterol, blood glucose, flu vaccination, childhood immunisation, bone density scan, prostate specific antigen, mammogram, contraceptive device implantation |
No benefit |
Sub-Limit Enhancer |
R100,000 sub-limit; R25,000 per claim, x2 per beneficiary: MRI scans, CT scans, internal prosthesis. |
No benefit |
No benefit |
Appliance Benefit |
R6,000 per annum, Gap portion only: hearing aids; wheelchairs; C-PAP machine; humidifiers; insulin pump; glucometer; nebuliser; introcular lenses. |
No benefit |
No benefit |
Frail Care |
R6,500 sub-limit. R800 per claim, x5 per beneficiary. |
No benefit |
No benefit |
Trauma Counselling |
R5,000 sub-limit, stated benefit of R750 per claim |
R3,000 sub-limit, stated benefit of R600 per claim |
No benefit |
医生诊所手术福利 |
標準排除不保項目等如下: 危險運動(例如橄欖球);嘗試自殺 / 自造傷害;酒精及藥物濫用;肥胖 / 不孕;愛滋病相關疾病; 例行治療(例如慢性病治療,腎臟透析); 放射線 / 核子武器 / 戰爭造成傷害; 心理/精神治療 根據短期保險法規,保險公司有權利可在給予客戶一個月通知後調整保費。 與醫療保險保費相比,此醫療附加險可說是物超所值,然而條件是投保人必須先有了醫療保險後才能購買此附加險。此醫療附加險可以與任何一家醫療保險配搭使用。 |
Premium |
Ultimate Gap |
Ultimate Gap |
Plus Gap |
Plus Gap |
Gap Cover |
Gap Cover |
Age |
64 Under |
65+ |
64 Under |
65+ |
64 Under |
65+ |
Individual |
R335 |
R435 |
R268 |
R367 |
R233 |
R320 |
Family |
R376 |
R490 |
R303 |
R416 |
R250 |
R344 |
癌症治疗自负额福利 |
舉例說明：某醫療保險癌症治療福利限額為R400,000, 若超過此額度客戶有20% 的自負額。若客戶已超支了此福利R100,000，則自負額為R20,000。此自付R20,000部分就可以向附加險公司索賠。 |
配搭任何医疗保险 |
標準排除不保項目等如下:
危險運動(例如橄欖球);嘗試自殺 / 自造傷害;酒精及藥物濫用;肥胖 / 不孕;愛滋病相關疾病; 例行治療(例如慢性病治療,腎臟透析); 放射線 / 核子武器 / 戰爭造成傷害; 心理/精神治療 根據短期保險法規,保險公司有權利可在給予客戶一個月通知後調整保費。 與醫療保險保費相比,此醫療附加險可說是物超所值,然而條件是投保人必須先有了醫療保險後才能購買此附加險。此醫療附加險可以與任何一家醫療保險配搭使用。 |