| 🟥 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 R35,000 per policy, with a maximum of R19,000 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 R6,500 per policy, R1,350 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 R14,000 per claim, per policy.
It is limited to 3 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 R26,500 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 R11,000 per policy. |
| 🟩 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 R12,000. |
| 🟪 Preventative Care | If your medical plan option includes preventative care benefits, an R4,000 sub-limit will apply.
Each claim will receive up to R800.
Covers pap smears, cholesterol tests, blood glucose testing, flu vaccines, etc.
The OAL governs this benefit. |
| 🟥 Appliances | Covers up to R7,000 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 R2,000 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 R8,000 per policy and R950 per claim 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 R6,500 per policy, R1,350 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 R1,250 minimum and an R5,000 maximum. Professionals offering primary care services include GPs, dentists, and alternative therapists. |
| 🟧 Value-Added Benefits | 🟧 Description |
| 🟨 Sira’GO Baby | A lump sum of R2,000 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 R5,250 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 R27,500 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: R16,000 for the Sirago policyholder, R11,000 for adult dependents, and R6,000 for child dependents. |
| 🟨 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 R20,000 per claim.
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.
If the scheme does not pay for the reconstruction of the healthy breast, the patient can receive up to R27,500.
To qualify for this benefit, the member must have taken a policy with Sirago during the mastectomy or held a policy for at least one year after transferring from another Gap Provider. |
