💙 Overall, Sirago Gap Cover is a trustworthy short-term insurance product designed to provide extra protection for those who already have medical aid. The Sirago Gap Cover Plans start from R172 ZAR on the Gap Liberal Plan. Sirago has a trust score of 4.4.
👉 Sirago Gap Cover has six plans to choose from:
✅ Sirago Exact Cover with Gap and Co-Pay
| 🟥 Date Established | 1993 |
| 🟧 Underwriters | GENRIC Insurance Company Limited (FSP: 43638) |
| 🟨 Headquartered | Eastern Free State, South Africa |
| 🟩 Number of Markets | South Africa |
| 🟦 Market Share | >10% |
| 🟪 The number of plans offered | 8 |
| 🟥 Mobile App offered | None |
| 🅰️ Age Limit | 🅱️ Monthly Contribution |
| 🟧 Overall Annual Limit per Beneficiary | R213,000 |
| 🟨 Price per Individual | R172 |
| 🟩 Price per Family | includes family up to certain dependants. |
| 🅰️ Age Limit | 🅱️ Monthly Contribution |
| 🟧 Overall Annual Limit per Beneficiary | R213,000 |
| 🟨 Price per Individual who is between 0 – 64 years old | R360 |
| 🟩 Price per Family with beneficiaries from 0 – 64 years old | R415 |
| 🅰️ Age Limit | 🅱️ Monthly Contribution |
| 🟧 Overall Annual Limit per Beneficiary | R213,000 |
| 🟨 Price per Individual who is between 0 – 64 years old | R401 |
| 🟩 Price per Family with beneficiaries from 0 – 64 years old | R461 |
| 🟦 Price per Individual who is >65 years old | R659 |
| 🟪 Price per Family with a beneficiary of >65 years old | R731 |
| 🅰️ Age Limit | 🅱️ Monthly Contribution |
| 🟧 Overall Annual Limit per Beneficiary | R213,000 |
| 🟨 Price per Individual who is between 0 – 64 years old | R466 |
| 🟩 Price per Family with beneficiaries from 0 – 64 years old | R563 |
| 🟦 Price per Individual who is >65 years old | R752 |
| 🟪 Price per Family with a beneficiary of >65 years old | R880 |
| 🅰️ Age Limit | 🅱️ Monthly Contribution |
| 🟧 Overall Annual Limit per Beneficiary | R213,000 |
| 🟨 Price per Individual who is between 0 – 64 years old | R583 |
| 🟩 Price per Family with beneficiaries from 0 – 64 years old | R704 |
| 🟦 Price per Individual who is >65 years old | R873 |
| 🟪 Price per Family with a beneficiary of >65 years old | R1032 |
| 🅰️ Age Limit | 🅱️ Monthly Contribution |
| 🟧 Overall Annual Limit per Beneficiary | R213,000 |
| 🟨 Price per Individual who is between 0 – 64 years old | R413 |
| 🟩 Price per Family with beneficiaries from 0 – 64 years old | R491 |
| 🟦 Price per Individual who is >65 years old | R896 |
| 🟪 Price per Family with a beneficiary of >65 years old | R1,110 |
👉 Choosing Sirago Gap Cover comes with a long list of advantages, including:
💙 With Sirago Gap Cover, you can focus on getting the medical treatment you need without worrying about the financial implications.
| 🟥 In-Hospital Benefits | 🟥 Description |
| 🟧 Gap Cover | Shortfall between the Medical Scheme Rate and the private rates (in-hospital) charged by the Medical Practioner or Specialist. Up to 400%, max 500% PMB cover only for use of a non-designated provider for a planned PMB procedure |
| 🟪 Robotic Surgery | Subject to OAL, R15 000 pp |
| 🟦 Co-payments and co-payments charged as a percentage | Subject to OAL of R213 000 |
| 🟧 Penalty Fee Co-payments | R12 000 pc, Max 2 claims pp |
| 🟨 Day Hospital, Clinic, In-Room | Subject to OAL |
| 🟩 Prescribed Minimum Benefits | Subject to OAL |
| 🟥 Hospital Account Shortfalls | R4 500 pp. R950 pc, including a Sub-Limit of R1 000 for PVT ward upgrades |
| 🟨 Sub-limit Enhancer | R30 000 pa. This benefit caters for all sub-limits. |
| 🟩 Step-down (includes accident, strokes and Cancer Treatment) | None |
| 🟥 Out- Hospital Benefits | 🟥 Description |
| 🟪 Specialist Consultation Fee | R4 500 sub-limit pp, R1 200 pc |
| 🟦 Casualty Benefit – After Hours (18:00 pm – 07:00 am) and all Saturdays, Sundays, and all Public Holidays | Sub-limit of R10 000 Accident & Trauma Child Casualty Illness – 12yrs & younger R2 000 pc – stated benefit. |
| 🟧 Trauma Counselling | R8 000 per policy, covered within the first 6 months after a traumatic event |
| 🟥 Cancer Benefits | 🟥 Description |
| 🟪 Cancer Co-payment Benefit | Subject to OAL |
| 🟨 Cancer Benefit – Boost | Subject to OAL |
👉 The following are excluded from the cover by Sirago Liberal Gap Cover:
💙 Participation in any race or speed test involving Mechanically propelled vehicles or crafts, as a professional athlete, or in any hobby is defined as dangerous in the Policy Terms and Conditions.
👉 Sirago Gap Liberal Cover applies the following waiting periods:
💙 Cover Upgrades of 3 months apply when existing policyholders with a previous 12-month consecutive cover upgrade to a higher plan. Those with <12 months of existing cover will wait for the difference between the remaining period and a 3-month waiting period.
💙 According to our research, Sirago Gap Liberal offers in-hospital benefits, covering the difference between medical scheme rates and charges from doctors and specialists. With premiums averaging R172 per month, it provides cover up to 400% above medical plan rates or the stated benefit value, governed by the Overall Annual Limit (OAL).
💙 We also found that Sirago Gap Liberal covers costs related to unapproved medical professionals for Prescribed Minimum Benefit (PMB) procedures.
👉 Sharpen your knowledge with a better understanding of Top Medical Aids in SA
💙 The Sirago Gap Core is one of six plans that starts from R360 per month. Sirago’s Gap Lite has benefits for in and out-of-hospital events, Sira’GO Baby, PMBs, accidental trauma and child emergencies, and more.
| 🅰️ In-Hospital Benefits | 🅱️ Description |
| 🟧 Gap Cover | This covers the difference (the shortfall or the gap) between what the medical scheme pays and the doctors and specialists charge in hospital. They settle claims at up to 350% above scheme rate to a maximum of 450% or at the stated benefit value. Subject to OAL |
| 🟨 Day Hospital, Clinic, In-Room | Pays the difference between what the hospital would have charged and what you paid for an outpatient procedure. Governed by the OAL. |
| 🟩 Co-Payments | Co-payment cover is for the co-payments (including co-payments expressed as a percentage), excesses, or deductibles as stipulated, or imposed by a medical scheme, for specified procedures, cover for hospital admission fees, or surgical procedures. The co-payment must be part of your medical scheme rules which will be highlighted on the authorisation for your procedure. Subject to the OAL. |
| 🟦 Penalty Fee Co-Payments | Covers penalty fees imposed by a medical scheme for using a non-designated service provider or network hospital. Sub-limit of R11,500 per claim, per policy. Governed by the OAL. |
| 🟪 Prescribed Minimum Benefits | All scheme members are entitled to the PMB, which covers diagnosis and treatment for predetermined conditions. Covers costs incurred from using an unapproved medical professional for scheduled PMB procedures. This applies if you meet the OAL. |
| 🟥 Hospital account shortfalls | This benefit will cover any charges, like consumables on the hospital account that the medical scheme has not paid. They also cover take-home medication that the medical scheme has not paid from risk. They pay up to R4 500 per policy, and R950 per claim, A sub-limit of R1 000 is available for private room upgrades. Subject to the OAL. |
| 🟧 Sub-limit Enhancer | This benefit has a sub-limit of R26 000 per policy, up to R13 000 per claim. Medical scheme benefits available on the medical scheme option for MRI & CT scans, internal prostheses, and Transcatheter Aortic Valve Implantation (TAVI) procedure valves only. When you exceed your medical scheme benefit limit during the time of the event, resulting in a shortfall or “gap”, they will pay the shortfall depending on the Gap option you are on. If you claim and your medical scheme limit has been reached at the time of the event, meaning it was used up before the claim event, and your medical scheme does not contribute anything towards this benefit, we will also not pay |
| 🅰️ Out-of-Hospital Benefits | 🅱️ Description |
| 🟧 Emergency Room Cover | This benefit will cover the shortfall for any day hospital, clinic, or in-room procedures including acute hospitals if a policyholder elects to have the treatment that would normally be performed in hospital, done in a day hospital, clinic, or in a doctor’s room by a registered medical professional. Subject to the OAL. |
| 🟨 Accidental and Trauma | All costs related to the initial accident/trauma event will be covered, whether you are liable to pay the costs out of your own pocket or if your medical scheme pays from your savings – stated benefit. |
| 🟩 Casualty benefits | There is a sub-limit of R2 000 for all Casualty Benefit. This benefit covers the initial emergency event at any registered casualty facility when you require immediate medical treatment due to an accident and trauma. We will cover a general practitioner (GP)’s consultation rooms if no other emergency facility is available within a 30 km radius. Ambulance costs are not covered by this benefit. |
| 🅰️ Value-Added Benefits | 🅱️ Description |
| 🟧 Sira’GO Baby | A lump sum of R1,500 for a newborn child is paid if the birth certificate is submitted within 90 days of birth. |
| 🟨 Sirago Medcare – Free ADR Service | This benefit gives you access to MedCare’s free ADR service for all disputed PMB claims exceeding R9 000. You can also access the MedCare service for all claims less than R9 000, including all potential medical scheme disputes, at a 60%, 20%, and/or 15% discounted rate depending on the required service. |
👉 The following are excluded from the cover by Sirago Gap Cover:
💙 Participation in any race or speed test involving Mechanically propelled vehicles or crafts, as a professional athlete, or in any hobby is defined as dangerous in the Policy Terms and Conditions.
👉 Sirago Gap Cover applies the following waiting periods:
💙 Cover Upgrades of 3 months apply when existing policyholders with a previous 12-month consecutive cover upgrade to a higher plan. Those with <12 months of existing cover will wait for the difference between the remaining period and a 3-month waiting period.
💙 In our experience, the Sirago Gap Core plan offers comprehensive coverage for individuals seeking additional financial protection beyond their medical scheme.
💙 With its cover for in-hospital benefits, day hospital procedures, co-payments, penalty fees, and Prescribed Minimum Benefits (PMB), the plan provides valuable support in covering medical expenses.
💙 However, it is important to note that Sirago Gap Core does have certain limitations. For example, we found that it does not provide cover for oncology benefits, scopes and scans, prostheses, trauma counseling, and some non-DSP co-payments.
| 🅰️ In-Hospital Benefits | 🅱️ Description |
| 🟧 Gap Cover | This covers the difference (the shortfall or the gap) between what the medical scheme pays and the doctors and specialists charge in hospital. They settle claims at up to 500% above scheme rate to a maximum of 600% or at the stated benefit value. For Robotic surgery claims that are reflected on the hospital account, they will cover up to a sub-limit of R12 000 per claim, maximum of 1 claim per policy |
| 🟨 Hospital Account Shortfall | This benefit will cover hospital account charges not covered by the medical plan, such as consumables and take-home medication. Sirago will pay up to R3,000 per policy, R500 per claim, and a maximum of three claims per beneficiary. A sub-limit of R1,000 applies to private room upgrades, and the OAL governs the benefit. |
| 🟩 Day Hospital, Clinic, In-Room | Covers the shortfall on any day hospital/clinic or in-room procedures if you elect to have the treatment normally performed in-hospital as an out-patient. Subject to the OAL. |
| 🟦 Co-Payments | Co-payment cover is for the co-payments (including co-payments expressed as a percentage), excesses, or deductibles as stipulated, or imposed by a medical scheme, for specified procedures, cover for hospital admission fees, or surgical procedures. The co-payment must be part of your medical scheme rules which will be highlighted on the authorisation for your procedure. They pay up to a sub-limit of R13 500 per claim. Subject to the OAL. |
| 🟪 Penalty Fee Co-Payments | Covers penalty fees imposed by a medical scheme for using a non-designated service provider or network hospital. Sub-limit of R8,000 per claim, per policy. Governed by the OAL. |
| 🟩 Prescribed Minimum Benefits | All scheme members are entitled to the PMB, which covers diagnosis and treatment for predetermined conditions. Covers costs incurred from using an unapproved medical professional for scheduled PMB procedures. This applies if you meet the OAL. |
| 🅰️ Out-of-Hospital Benefits | 🅱️ Description |
| 🟧 Emergency Room Cover | There is a sub-limit of R8 000 per policy for all Casualty Benefit. This benefit covers the initial emergency event at any registered casualty facility when you require immediate medical treatment due to an accident and trauma, or illness. We will cover a general practitioner (GP)’s consultation rooms if no other emergency facility is available within a 30 km radius. Ambulance costs are not covered by this benefit |
| 🟨 Appliances | Covers up to R4,000 per policy and R1,300 per claim. Covers the difference between the tariff of the medical scheme and the service provider on hearing aids, wheelchairs, humidifiers, etc. |
| 🟩 Accidental and Trauma | Covers all costs associated with accidents or traumatic events. |
| 🟦 Child Emergency Illness | All costs related to the initial emergency illness event will be covered and paid up to R2 000 per claim of the sub-limit, if you are liable to pay the costs out of your own pocket, or if paid from your medical scheme savings. This is applicable to any beneficiary 12 years and younger who needs emergency treatment outside of normal consultation hours or treatment that can only be done in an emergency facility |
| 🅰️ Value-Added Benefits | 🅱️ Description |
| 🟧 Sira’GO Baby | A lump sum of R1,500 for a newborn child is paid if the birth certificate is submitted within 90 days of birth. |
| 🟨 Sirago Medcare – Free ADR Service | Offers free alternative dispute resolution (ADR) service for PMB claims over R9,000 not considered valid. Provides discounted rates (60%, 20%, or 15%) for claims under R9,000, including non-scheme disputes. |
| 🟩 Premium Waiver | In the event of accidental death only or total permanent disability of the Sirago policyholder, we will keep the premiums for your policy as a credit for 6 months. This benefit may be claimed by the surviving spouse or adult dependent on the Sirago policy. |
| 🅰️ Cancer Benefits | 🅱️ Description |
| 🟧 Cancer Co-Payments | This applies if your medical plan’s cancer benefit has been exhausted and a co-payment is required. Includes co-payments for ongoing cancer treatments and biological medications. Ongoing treatment must comply with your medical plan’s registered treatment plan to be eligible for this benefit of up to R22,000 per claim. The Overall Annual Limit (OAL) governs this benefit. |
| 🟨 Cancer Boost | The Cancer Boost Benefit is applicable to policyholders whose medical scheme option has a defined rand limit for cancer treatment and the rand limit on the medical scheme has been reached. They will cover the costs of ongoing treatment in line with the medical scheme’s registered treatment plan once the rand limit has been reached. Subject to the OAL. |
👉 The following are excluded from the cover by Sirago Gap Cover:
💙 Participation in any race or speed test involving Mechanically propelled vehicles or crafts, as a professional athlete, or in any hobby is defined as dangerous in the Policy Terms and Conditions will be excluded.
👉 Women might consider making use of our free Ovulation Calculator
👉 Sirago Gap Cover applies the following waiting periods:
💙 Cover Upgrades of 3 months apply when existing policyholders with a previous 12-month consecutive cover upgrade to a higher plan. Those with <12 months of existing cover will wait for the difference between the remaining period and a 3-month waiting period.
👉 Discover the Best Gap Cover with No Waiting Period
💙 In our experience, Sirago Gap Assist offers a comprehensive range of benefits, including in-hospital cover, co-payment cover, and cancer benefits. In addition, the tiered premium structure provides flexibility for different budgets and needs.
💙 Unique benefits like the Sira’GO Baby and Sirago Medicare-Free ADR Service add value. However, the lack of cover for scopes and scans, trauma counseling, travel cover extender, and accidental death/permanent disability cover may be drawbacks for some.
💙 The plan’s exclusions and waiting periods are standard but should be considered. Overall, Sirago Gap Assist provides robust cover and valuable financial protection against high healthcare costs, but individual healthcare needs and circumstances should be considered before choosing a plan.
💙 The Sirago Plus Gap is one of six plans that starts from R466 per month. Sirago’s Plus Gap has benefits for hospital account shortfalls, PMBs, preventative care, illness, specialist consultation, trauma counseling, and more.
| 🟥 In-Hospital Benefits | 🟥 Description |
| 🟧 Gap Cover | Gap Cover pays the difference between the medical scheme rate and the rate service providers charge, i.e., doctors and specialists. The cover extends to 500% above the medical scheme rate or the stated benefit value, with a maximum of 600%. Covers up to R17 000 per policy, with a maximum of R6 000 per claim per beneficiary on robotic surgery. Subject to the OAL. |
| 🟨 Hospital Account Shortfall | This benefit will cover hospital account charges not covered by the medical plan, such as consumables and take-home medication. Sirago will pay up to R4,500 per policy, R1000 per claim, and a maximum of three claims per beneficiary. A sub-limit of R1,100 applies to private room upgrades, and the OAL governs the benefit. |
| 🟩 Day Hospital, Clinic, In-Room | Covers the shortfall on any day hospital/clinic or in-room procedures if you elect to have the treatment normally performed in-hospital as an out-patient. Subject to the OAL. |
| 🟦 Co-Payments | The Co-payment Cover feature is intended to cover co-payments, excesses, and deductibles imposed by a medical scheme for specified procedures, hospital admission fees, scans, or surgical procedures. |
| 🟪 Penalty Fee Co-Payments | Covers penalty fees imposed by a medical scheme for using a non-designated service provider or network hospital. Sub-limit of R13,000 per claim, per policy. Governed by the OAL. |
| 🟥 Sub-Limit Enhancer | This benefit is subject to a sublimit of R36,000 per policy and R12,000 per claim. The sub-limit enhancer benefit is applicable when you have exceeded your medical plan’s benefit limit for MRI and CT scans and internal prostheses. The OAL governs this benefit. |
| 🟧 Prescribed Minimum Benefits | All scheme members are entitled to the PMB, which covers diagnosis and treatment for predetermined conditions. Covers costs incurred from using an unapproved medical professional for scheduled PMB procedures. This applies if you meet the OAL. |
| 🟨 Out-of-Hospital Benefits | 🟨 Description |
| 🟩 Emergency Room Cover | Covers emergency costs at registered emergency facilities, hospitals, or casualty centers. There is a sub-limit of R15,000. They will cover a general practitioner (GP)’s consultation rooms if no other emergency facility is available within a 30 km radius. Ambulance costs are not covered by this benefit. |
| 🟦 Preventative Care | If your medical plan option includes preventative care benefits, an R5,000 sub-limit will apply. Each claim will receive up to R950. Covers pap smears, cholesterol tests, blood glucose testing, flu vaccines, etc. The OAL governs this benefit. |
| 🟪 Appliances | Covers up to R5,500 Covers the difference between the tariff of the medical scheme and the service provider on the following appliances: hearing aids, wheelchairs, continuous positive airway pressure (CPAP) machines, humidifiers, insulin pumps, glucometers, nebulisers, and Mirena devices. |
| 🟥 Accidental and Trauma | Covers all costs associated with accidents or traumatic events. |
| 🟧 Illness | All costs associated with the emergency illness event will be covered and paid up to the sub-limit of R1,000 if you are responsible for paying the costs out of pocket or if paid from your medical scheme savings. |
| 🟨 Child Emergency Illness | Covers emergency treatment for children 8 and younger outside normal consultation hours. Covers all costs related to the event. Subject to the OAL. |
| 🟩 Trauma Counselling | This benefit covers trauma counseling with a registered medical professional following a traumatic event, such as dread disease, hijacking, or violent crime. A sublimit of R6,000 per policy . You are covered for the first six months following the incident. |
| 🟦 Day-to-Day Specialist Consultations | This benefit covers the difference between the medical scheme rate and the specialist’s consultation rate only if your medical aid pays a portion of the fee from your savings. Sub-limits of R5000 per policy, R1000 per claim, and three claims per beneficiary apply. The benefit is subject to the OAL. |
| 🟪 Value-Added Benefits | 🟪 Description |
| 🟥 Sira’GO Baby | Sirago will pay out a lump sum of R2 000 to you, per newborn baby, when the baby is registered on your gap policy within 90 days of birth. To register your newborn(s), Simply fill out the additional dependant form and submit it to [email protected] together with your baby’s birth certificate. |
| 🟧 Sirago Medcare – Free ADR Service | Offers free alternative dispute resolution (ADR) service for PMB claims over R9,000 not considered valid. Provides discounted rates (60%, 20%, or 15%) for claims under R9,000, including non-scheme disputes. |
| 🟨 Premium Waiver (Gap Cover) | If the Sirago policyholder dies or becomes totally and permanently disabled, the surviving spouse or adult dependent may file a claim for a Premium Waiver benefit. ·Sirago will hold your policy’s premiums as a credit for six months. |
| 🟩 Premium Waiver (Medical Aid) | Sirago will pay the medical scheme premium, up to R4,000 monthly over six months. In the event of the death or total and permanent disability of the Sirago policyholder and where all beneficiaries are linked to a single medical scheme, this will be paid to the beneficiary for the maintenance of medical scheme contributions. |
| 🟦 Initial Cancer Diagnosis | This benefit will pay a lump sum of R20,000 upon the initial diagnosis of stage 1 cancer. Before the policy is started, any cancer or pre-cancer is excluded, including skin cancer. |
| 🟪 Accidental Death | This benefit will be paid out in the event of accidental death at the following rates: R9,000 for the Sirago policyholder and R3,000 for child dependents. |
| 🟥 Cancer Benefits | 🟥 Description |
| 🟧 Cancer Co-Payments | This benefit applies if your medical scheme cancer benefit has been reached and a percentage co-payment is imposed. This benefit incorporates co-payments for ongoing cancer-related treatments and biological drugs. Ongoing treatment must be in line with the registered treatment plan of your medical scheme to access this benefit. Subject to the OAL. |
👉🏿 The following are excluded from the cover by Sirago Gap Cover:
💙 Participation in any race or speed test involving Mechanically propelled vehicles or crafts, as a professional athlete, or in any hobby is defined as dangerous in the Policy Terms and Conditions.
👉🏿 Sirago Gap Cover applies the following waiting periods:
💙 Cover Upgrades of 3 months apply when existing policyholders with a previous 12-month consecutive cover upgrade to a higher plan. Those with <12 months of existing cover will wait for the difference between the remaining period and a 3-month waiting period.
👉🏿 Read more about the 5 Top Medical Aids for Childbearing Women
💙 According to our research, the Sirago Plus Gap plan offers a comprehensive suite of benefits that cater to a wide range of healthcare needs. The plan’s in-hospital benefits, co-payment cover, and cancer benefits are particularly noteworthy, providing substantial financial protection against the high costs of medical treatments and procedures.
💙 Including unique benefits such as the Sira’GO Baby benefit, Sirago Medcare – Free ADR Service, and the Premium Waiver adds value to the plan and demonstrates Sirago’s commitment to providing comprehensive and customer-focused solutions.
💙 However, it is important to note that the plan does have some limitations.
💙 The Sirago Ultimate Gap is one of six plans that starts from R583 per month. Sirago’s Ultimate Gap has benefits for in and out-of-hospital treatment and procedures, penalty fees, step-down facilities, illness, primary care, and more.
| 🟥 In-Hospital Benefits | 🟥 Description |
| 🟧 Gap Cover | Gap Cover pays the difference between the medical scheme rate and the rate service providers charge, i.e., doctors and specialists. The cover extends to 500% above the medical scheme rate or the stated benefit value, with a maximum of 600%. With a maximum of R37,500 per claim per beneficiary on robotic surgery. Subject to the OAL. |
| 🟨 Hospital Account Shortfall | This benefit will cover hospital account charges not covered by the medical plan, such as consumables and take-home medication. Sirago will pay up to R7,800 per policy, R1,500 per claim, and a maximum of three claims per beneficiary. A sub-limit of R2,000 applies to private room upgrades, and the OAL governs the benefit. |
| 🟩 Day Hospital, Clinic, In-Room | Covers the shortfall on any day hospital/clinic or in-room procedures if you elect to have the treatment normally performed in-hospital as an out-patient. Subject to the OAL. |
| 🟦 Co-Payments | The Co-payment Cover feature is intended to cover co-payments, excesses, and deductibles imposed by a medical scheme for specified procedures, hospital admission fees, scans, or surgical procedures. |
| 🟪 Penalty Fee Co-Payments | Covers penalty fees imposed by a medical scheme for using a non-designated service provider or network hospital. Sub-limit of R16,000 per claim, per policy. It is limited to 2 claims per policy, regardless of whether the medical scheme charges a rand amount or a percentage penalty fee. Governed by the OAL. |
| 🟥 Sub-Limit Enhancer | This benefit is subject to a sublimit of R40,000 per claim. The sub-limit enhancer benefit is applicable when you have exceeded your medical plan’s benefit limit for MRI and CT scans and internal prostheses. The OAL governs this benefit. |
| 🟧 Prescribed Minimum Benefits | All scheme members are entitled to the PMB, which covers diagnosis and treatment for predetermined conditions. Covers costs incurred from using an unapproved medical professional for scheduled PMB procedures. This applies if you meet the OAL. |
| 🟨 Step-Down Facilities | If your medical scheme provides benefits for rehabilitation as an in-patient in a step-down or sub-acute facility. There is a sub-limit of R15,000 per policy. |
| 🟩 Out-of-Hospital Benefits | 🟩 Description |
| 🟦Casualty Benefit | There is a sub-limit of R20 000 per policy for all Casualty Benefit. This benefit covers the initial emergency event at any registered casualty facility when you require immediate medical treatment due to an accident and trauma, or illness. They will cover a general practitioner (GP)’s consultation rooms if no other emergency facility is available within a 30 km radius. Ambulance costs are not covered by this benefit |
| 🟪 Preventative Care | If your medical plan option includes preventative care benefits, an R8,500 sub-limit will apply. Each claim will receive up to 1,35000. Up to R500 will be paid towards the following tests and treatments, 2 claims per policy: Pap smear. Child Immunisations (Department of Health Formulary) – up to the age of 12 years. Mammogram. Bone density scans The OAL governs this benefit. |
| 🟥 Appliances | Covers up to R8,250 per policy. Covers the difference between the tariff of the medical scheme and the service provider on hearing aids, wheelchairs, humidifiers, etc. |
| 🟧 Accidental and Trauma | Covers all costs associated with accidents or traumatic events. |
| 🟨 Illness | All costs associated with the emergency illness event will be covered and paid up to the sub-limit of R2,500 if you are responsible for paying the costs out of pocket or if paid from your medical scheme savings. |
| 🟩 Child Emergency Illness | All costs related to the initial emergency illness event will be covered and paid up to R4 000 per claim of the sub-limit, if you are liable to pay the costs out of your own pocket, or if paid from your medical scheme savings. This is applicable to any beneficiary 12 years and younger who needs emergency treatment outside of normal consultation hours or treatment that can only be done in an emergency facility. Subject to the OAL. |
| 🟦 Trauma Counselling | This benefit covers trauma counseling with a registered medical professional following a traumatic event, such as dread disease, hijacking, or violent crime. A sublimit of R10,000 per policy will apply. You are covered for the first six months following the incident. |
| 🟪 Day-to-Day Specialist Consultations | This benefit covers the difference between the medical scheme rate and the specialist’s consultation rate only if your medical aid pays a portion of the fee from your savings. Sub-limits of R7,000 per policy, R1,500 per claim, and three claims per beneficiary apply. The benefit is subject to the OAL. |
| 🟥 Primary Care Benefit | The Primary Care gap cover pays the difference between the medical scheme rate and the provider rate for the consultation fee and any additional services charged and included in the consultation fee. Each claim is subject to an R850 per claim and an R5,500 maximum. Professionals offering primary care services include GPs, dentists, and alternative therapists. |
| 🟧 Value-Added Benefits | 🟧 Description |
| 🟨 Sira’GO Baby | A lump sum of R2,500 for a newborn child is paid if the birth certificate is submitted within 90 days of birth. |
| 🟩 Sirago Medcare – Free ADR Service | Offers free alternative dispute resolution (ADR) service for PMB claims over R9,000 not considered valid. Provides discounted rates (60%, 20%, or 15%) for claims under R9,000, including non-scheme disputes. |
| 🟦 Premium Waiver (Gap Cover) | If the Sirago policyholder dies or becomes totally and permanently disabled, the surviving spouse or adult dependent may file a claim for a Premium Waiver benefit. Sirago will hold your policy’s premiums as a credit for six months. |
| 🟪 Premium Waiver (Medical Aid) | Sirago will pay the medical scheme premium, up to R5,800 monthly over six months. In the event of the death or total and permanent disability of the Sirago policyholder and where all beneficiaries are linked to a single medical scheme, this will be paid to the beneficiary for the maintenance of medical scheme contributions. |
| 🟥 Initial Cancer Diagnosis | This benefit will pay a lump sum of R33,000 upon the initial diagnosis of stage 1 cancer. Before the policy is started, any cancer or pre-cancer is excluded, including skin cancer. |
| 🟧 Accidental Death | This benefit will pay out for accidental death at R15 000 for adult dependants and R6 000 for child dependants registered on the policy. |
| 🟨 Cancer Benefits | 🟨 Description |
| 🟩 Cancer Co-Payments | This benefit applies if your medical scheme cancer benefit has been reached and a percentage co-payment is imposed. This benefit incorporates co-payments for ongoing cancer-related treatments and biological drugs. Ongoing treatment must be in line with the registered treatment plan of your medical scheme to access this benefit. The Overall Annual Limit (OAL) governs this benefit. |
| 🟦 Cancer Boost | If your medical scheme for cancer has a set dollar amount, you may be eligible for this benefit. After the initial rand limit is met, Sirago will cover ongoing treatment costs according to the medical scheme’s registered treatment plan. |
| 🟪 Cancer Breast Reconstruction | Sirago will pay for reconstructive surgery on the amputated breast after a mastectomy if your medical aid allows it. Up to R40 000 will be paid for the reconstruction of the unaffected breast if there is no payment by the scheme. They will also pay up to R4 000 of the R40 000 sub-limit for artificial prosthesis, including but not limited to wigs, breast implants, and post-mastectomy bra prosthesis, should the medical scheme not cover this at all. This benefit is only available within the first 18 months of the initial mastectomy. There is no benefit for any costs related to PMB services, treatments, or medical interventions, unless otherwise stated. |
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👉🏿 The following are excluded from the cover by Sirago Gap Cover:
👉🏿 Participation in any race or speed test involving Mechanically propelled vehicles or crafts, as a professional athlete, or in any hobby is defined as dangerous in the Policy Terms and Conditions.
💙 Sirago Gap Cover applies the following waiting periods:
💙 Cover Upgrades of 3 months apply when existing policyholders with the previous 12-month consecutive cover upgrade to a higher plan. Those with <12 months of existing cover will wait for the difference between the remaining period and a 3-month waiting period.
💙 According to our research, the Sirago Ultimate Gap plan offers a comprehensive range of benefits catering to various healthcare needs. The plan’s robust in-hospital and out-of-hospital benefits and unique value-added benefits provide substantial financial protection against the high costs of medical treatments and procedures.
💙 However, the plan does have some limitations. For example, in our experience, the lack of a travel cover extender may be a significant drawback for some potential policyholders.
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💙 The Exact with Gap and Co-Pay option provides supplementary cover for services not included in your medical scheme, including those procedures that your Medical Scheme option specifically excludes in addition to its standard exclusions. This option avails a specific list of procedures. Sirago takes responsibility for negotiating with service providers and directly paying for your claim up to the amounts specified below.
💙 The cover includes the total cost incurred at the hospital and by any other service providers. However, members should note that the following limits apply to Exact Cover:
| 🟥 Procedure | 🟧 Cover Limit | 🟨 Procedure | 🟩 Cover Limit |
| 🟧 Arthroscopic Surgery | R90,000 | Joint Replacement Surgery | R55,000 |
| 🟨 Back and Neck Surgery | R90,000 | Oesophageal reflux and hiatus hernia surgery | R60,000 |
| 🟩 Bunion Surgery | R20,000 | Varicose vein surgery | R22,500 |
| 🟦 A cochlear implant, auditory brain implant, and internal nerve Stimulator surgery, including the device and processor | R85,000 | Knee and shoulder surgery | R30,000 |
| 🟪 Dental procedures for reconstructive plastic surgery due to an accident | R80,000 | MRI and CT scans due to an accident | R10,000 |
| 🟥 Dental procedures for impacted wisdom teeth for children under 18 years old | R15,000 | Tonsillectomy, Grommets, and Adenoidectomy | Single : R10 000 Combined : R15 000 |
| 🟧 Functional Nasal Surgery | R30,000 | Skin disorders, including benign growths and lymphoma | R20,000 |
| 🟨 Non-cancerous breast conditions | R20,000 | Endoscopic Procedures | R8,000 |
💙 Any remaining costs after Sirago has paid up to the cover limit for the approved procedure.
👉 Sirago Gap Cover applies the following waiting periods on Exact Cover with Gap and Co-Pay:
💙 Pre-existing conditions, specific diseases, and illnesses associated with the services must undergo a 12-month waiting period before receiving treatment.
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💙 According to our research, the Sirago Exact Cover with Gap and Co-Pay offers a comprehensive in-hospital cover plan that can supplement your medical scheme, especially for typically excluded procedures.
💙 However, it does have its limitations, particularly when it comes to out-of-hospital treatments, maternity, and cancer coverage. As with any insurance product, it is important to carefully consider your personal health needs and circumstances before choosing a plan.
👉 To apply for Gap Cover with Sirago, follow these easy steps:
👉 Complete the following application sections:
👉 Read the terms and conditions before downloading, saving, and emailing the application to Sirago.
👉 To change your option with Sirago, follow these steps:
👉 Complete the needed application sections.
👉 To submit a claim with Sirago, follow these steps:
The claim will be submitted to Sirago, and an agent will contact you to provide an update or to request more information.
💙 The Sirago Gap Cover Exclusions and Waiting Periods apply to all plans except the exact cover.
Policy Exclusions
👉 Benefits are not paid for the following exclusions:
Short-Term Exclusions
👉 Sirago Gap Cover does not cover the following:
General Exclusions
👉 The following are excluded from the cover by Sirago Gap Cover:
General Waiting Periods
Policy-Specific Waiting Periods
Certain Benefit Categories
Transfer of Cover
Cover Upgrades
💙 If a Sirago policyholder with less than 12 consecutive months of cover wishes to upgrade to a higher option, the difference between the remaining and a 3-month waiting period on additional benefits will be applied.
| 🔎 Gap Cover Provider | 🥇 Sirago | 🥈 Discovery Health | 🥉 Liberty |
| 🟥 Underwriters | Sirago Underwriting Managers | Discovery Insure Ltd | Guardrisk Life Limited (FSP 76) |
| 🟧 Number of Plans | 6 | 2 | 2 |
| 🟨 Average Price From | R172 | R157 | R253 |
| 🟩 Waiting Periods | 3 months | 12 Months | 12 Months |
| 🟦 Exclusions | ✅ Yes | ✅ Yes | ✅ Yes |
| 🟪 Oncology Benefit | ✅ Yes | ✅ Yes | ✅ Yes |
| 🟥 In-Hospital Benefit | ✅ Yes | ✅ Yes | ✅ Yes |
| 🟧 Out-of-Hospital Cover | ✅ Yes | ✅ Yes | ✅ Yes |
| 🟨 Maternity Benefit | ✅ Yes | ✅ Yes | ✅ Yes |
| 🟩 Scopes and Scans | None | ✅ Yes | ✅ Yes |
| 🟦 Co-payment Cover | ✅ Yes | None | ✅ Yes |
| 🟪 Emergency Room | ✅ Yes | None | ✅ Yes |
| 🟥 Accidental Cover | ✅ Yes | None | ✅ Yes |
| 🟧 Trauma Counseling | ✅ Yes | None | ✅ Yes |
| 🟨 Premium Waiver | ✅ Yes | None | ✅ Yes |
| 🟩 Non-DSP Co-Payment | ✅ Yes | None | ✅ Yes |
| 🟦 Prostheses | None | None | ✅ Yes |
| 🟪 Accidental Death/ Permanent Disability | ✅ Yes | ✅ Yes | None |
| 🟥 Travel Cover Extender | None | None | ✅ Yes |
| ✅ Pros | ❌ Cons |
| Sirago Gap Cover is adaptable because it gives you the freedom to pick the level of protection that is most suitable for you from among several available alternatives | Additional insurance like Sirago Gap Cover comes with a monthly premium. The total cost of your insurance policy may go up because of this |
| Reimbursement for covered expenses is simple with Sirago Gap Cover’s streamlined claims process | Sirago Gap Cover has restrictions on the types of medical services and procedures that are paid for |
| Sirago Gap Cover is a financial safety net that pays for healthcare costs not covered by your medical scheme. This aids in making sure that you do not have to shell out a lot of cash for medical care. | The policy’s terms, conditions, and benefits can be confusing to consumers |
👉 READ more about the 5 Best Gap Cover Options for Under R200
💙 Sirago Gap Cover is a comprehensive gap cover that compensates for the difference between the medical scheme rate and the provider rate. As a result, the medical scheme rate is increased by 500%, much more than other gap covers in South Africa.
💙 This benefit covers emergency care for an accident, injury, or illness at any registered emergency facility. Sirago stands out as it offers more options than most other providers, and South Africans can choose a plan that suits their needs perfectly instead of settling for one of two options.
💙 Sirago offers several benefits on each tier of gap cover and even provides a specific and tailor-made option for Government Employees in South Africa.
Sirago Gap Cover is a type of insurance policy that helps cover the gap between the amount medical schemes pay for medical services and the actual cost of those services. It is meant to provide an extra layer of financial protection for policyholders.
Sirago offers Six different plans: Gap Liberal, Gap Core, Gap Assist, Plus Gap, Ultimate Gap and lastly Exact Cover with Gap.
Eligibility for Sirago Gap Cover is typically dependent on the specific policy. However, individuals who are members of a medical scheme are generally eligible to apply for gap cover.
Sirago Gap Cover covers the difference between the amount medical schemes pay for medical services and the actual cost of those services up to a specified limit. This includes costs related to emergency room visits, accidental injuries, illnesses, specialist consultations, and more.
Sirago Gap Cover is typically taken in conjunction with a medical scheme, but this varies depending on the specific policy. Furthermore, you do not need to use the gap cover of a medical scheme, and you can choose your own gap cover if your scheme allows this. However, not all medical aid schemes in South Africa offer gap cover, and members must arrange their own.
The cost of Sirago Gap Cover varies depending on factors such as the specific policy, the level of cover, and the policyholder’s age and health status. Sirago’s plans start from R172 for basic gap cover.
Yes, you can change your Sirago Gap Cover option if it no longer meets your needs.
Yes, there are limitations and exclusions for Sirago Gap Cover, such as certain medical conditions or treatments that are not covered. These limitations or exclusions will depend on your gap cover plan with Sirago.
To claim with Sirago Gap Cover, you may need to provide specific information and documentation, such as proof of medical expenses and a letter from your medical scheme.
Adriaan holds an MBA and specializes in medical aid research. With his commitment to perfection, he ensures the accuracy of all data presented on medicalaid.com every three months. When he is not conducting research, Adriaan can be found indulging in his passion for trout fishing amidst nature.
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