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FAQ
If your query isn’t covered in our FAQ below, please get in touch with us for more information.
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What is Gap Cover
Gap Cover is insurance that supplements your medical scheme cover to ensure that you are not left with amounts still owing to doctors after major medical treatment.
What does it cover me for?
If your query isn’t covered in our FAQ below, please get in touch with us for more information.
What additional benefits are included?
If your query isn’t covered in our FAQ below, please get in touch with us for more information.
How does Cinagi Gap Cover give me peace of mind?
Besides the financial security provided by our comprehensive benefits, Cinagi also gives you access to the world’s best doctors when you are required to make a major medical treatment decision. All Cinagi members have access to the Medical Second Opinion (MSO) service provided by our partners, Mediguide International. This allows you to get a review of your local diagnosis and tests by internationally renowned doctors at top medical facilities, such as Cleveland Clinic, John Hopkins, Harvard Medical School, etc. There are more than 100 world class facilities from which you can choose, giving you total peace of mind that before you decide on treatment, you are certain of the diagnosis and what treatment options are available.
What is excluded from cover?
In general, the main treatments that gap cover does not cover are routine day-to-day care, specialised dentistry, claims when you are in your self-payment gap, chronic medicines and any service that is excluded by your medical scheme (gap cover is only allowed to cover shortfalls on services that are covered by your scheme).
How do I apply for cover?
Cinagi has an easy, online process for you to apply – you can click here to apply. Make sure you consult with your healthcare broker before applying – if you do not have a broker, please contact us and we will refer you to one of our preferred brokers.
Who can I cover on my policy?
Your spouse and/or children are eligible for cover under your policy and you must all be covered under the same medical scheme membership. If you have split medical scheme membership in your family, you will need to take out 2 separate policies.
What waiting periods apply?
If you do not currently have gap cover with another provider, a 3-month general and 12-month condition specific waiting period will apply.
Can I transfer my existing Gap Cover to Cinagi?
Yes – on the application form we ask if you have existing cover and the details thereof. We will then be able to inform you if you will have any waiting periods. In most instances, you will be able to transfer to Cinagi without any waiting periods.
I currently have Cinagi Gap Cover on my employer's group scheme - can I continue with cover in my private capacity if I resign from my employer?
Yes – you can transfer your cover and if your employer was deducting and paying across the monthly premiums, you will have to complete a debit order authority for us to deduct the monthly premiums. If you have been on your employer’s group scheme for more than 12 months, you will not have any waiting periods applied. Your new premium may also change depending on your employer’s group scheme rate.
Claims
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An additional 500% cover on GapCORE and 600% on Gap MAX is provided over and above the medical scheme benefit for approved oncology and in-hospital procedures/treatment.
This cover only applies to the individual practitioners providing their in-patient services. Any additional charges from the hospital or facility are excluded.
HOW TO SUBMIT A CLAIM
Members can submit their claim online and upload the supporting documentation at Cinagi Claim Form. Members will be guided as to what supporting documents are required.
HOW LONG DOES IT TAKE TO PROCESS A CLAIM?
Cover applies to treatment approved by a member’s medical scheme for either traditional chemotherapy or modern biological drugs.
(Note: we do not cover oncology shortfalls where a member exceeds a benefit limit applied by their medical scheme or where certain cancer types are excluded by the medical scheme).
We further cover the co-payments on innovative medicine up to R12,500 on GapCORE and R15,000 on Gap MAX per claim.
If your medical scheme approves ex-gratia benefits for oncology medicines, we will provide additional cover for your portion of the costs. (Subject to OAL):
GapCORE : R12,500 per claim/ R25,000 per medicine cycle
Gap MAX : R15,000 per claim/ R30,000 per medicine cycle
HOW DO I SUBMIT ADDITIONAL DOCUMENTATION?
If there is outstanding documentation, the member will receive a notification from us detailing exactly what is still outstanding, with a link that can be used to upload the outstanding document/s.
DOES CINAGI HAVE A PDF VERSION OF THE CLAIM FORM?
WHAT DOCUMENTS NEED TO BE SUBMITTED WITH EACH CLAIM?
HOW CAN I FOLLOW UP ON THE STATUS OF A CLAIM?
CINAGI GAP BENEFITS
Gap Cover Benefits
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An additional 500% cover on GapCORE and 600% on Gap MAX is provided over and above the medical scheme benefit for approved oncology and in-hospital procedures/treatment.
This cover only applies to the individual practitioners providing their in-patient services. Any additional charges from the hospital or facility are excluded.
TARRIF SHORTFALL
An additional 500% cover on GapCORE and 600% on Gap MAX is provided over and above the medical scheme benefit for approved oncology and in-hospital procedures/treatment.
This cover only applies to the individual practitioners providing their in-patient services. Any additional charges from the hospital or facility are excluded.
ONCOLOGY
The 20% co-payment that arises after the oncology threshold is reached. This only applies to certain options on Discovery and Momentum medical schemes.
Cover applies to treatment approved by a member’s medical scheme for either traditional chemotherapy or modern biological drugs.
(Note: we do not cover oncology shortfalls where a member exceeds a benefit limit applied by their medical scheme or where certain cancer types are excluded by the medical scheme).
We further cover the co-payments on innovative medicine up to R12,500 on GapCORE and R15,000 on Gap MAX per claim.
If your medical scheme approves ex-gratia benefits for oncology medicines, we will provide additional cover for your portion of the costs. (Subject to OAL):
GapCORE : R12,500 per claim/ R25,000 per medicine cycle
Gap MAX : R15,000 per claim/ R30,000 per medicine cycle
UPFRONT PAYMENTS
Where fixed value upfront payments are required for the following in-hospital treatment:
- Endoscopes
- Specialised scans (MRI/CT/PET)
- Basic dentistry (eg fillings for young children, wisdom teeth extraction)
- Surgical procedures defined by a medical scheme (eg Priority plans)
(Note: where schemes apply upfront payments (including co-payments and/or deductibles) as percentages of the treatment cost, the policy benefit is limited to a maximum of R10,000 per event).
If a co-payment is applied for involuntary use of a non-DSP hospital or day clinic, we will cover one such co-payment per
annum per policy, subject to a maximum of R12,000 on Gap CORE and two co-payments per annum per policy, subject to a maximum R18,000 on Gap MAX
LIMIT PLUS
Extender Cover
Below is a summary of the benefit categories under Extender Cover.
Each benefit category below has its own limitation, and these are not subject to the overall statutory limit on the gap cover benefits
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An additional 500% cover on GapCORE and 600% on Gap MAX is provided over and above the medical scheme benefit for approved oncology and in-hospital procedures/treatment.
This cover only applies to the individual practitioners providing their in-patient services. Any additional charges from the hospital or facility are excluded.
CASUALTY COVER
Limited to 2 events per annum and :
GapCORE – R14,000 per event
Gap MAX – R18,000 per event
Note :Benefits only apply for treatment received within 12 hours of the accident and excludes cover for specialised radiology scans and prosthetic devices.
ACCIDENTAL SPORTS COVER
If after claiming on the Casualty Cover above, the accident occurred during practice or a social sporting event, shortfalls on rehabilitative consultations (physiotherapy or chiropractic) will be covered up to R460 per consult for a maximum of 6 consultations if on GapCORE or up to R680 per consult for a maximum of 6 consultations if on Gap MAX
This cover is limited to one event per year and the consultations must occur within 6 weeks of the accident.
TRAVEL COVER
Covers the excess on international travel insurance claims for emergency events while travelling outside of the country.
There is no limit on the number of events annually but there is a limit of one event per international outbound trip subject to a maximum claim of R2,400 on GapCORE and R3,400 on GapMAX
CANCER DIAGNOSIS
HOSPITAL COVER
ACCIDENT COVER
WAIVER COVER
Medical Second Opinion
If you are diagnosed with a serious illness, Mediguide International’s global panel of World Leading Medical Research Centres gives you access to the world’s top medical minds for a diagnosis review.
This ensures that your diagnosis is 100% accurate and your treatment plan is optimally structured for you to achieve the best possible health outcome.
Click here if you would like to find out more about Medical Second Opinion.
Marketing Material
You can find all of our 2024 material for each of our products on the relvant product page :
Commission
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HOW IS COMMISSION CALCULATED?
Commission on on Cinagi Gap products are calculated in line with the table below :
Monthly premium band | Maximum Commission Level |
Above R1,200 | 5% |
R601 to R1,200 | 10% |
R300 to R 600 | 15% |
Less than R300 | 20% |
Example:
Mr.A has a Cinagi Gap Cover policy with a premium of R520 per month. The commission payable is equal to the below :
(R300 x 20%) +(R220 x 15%) = R93.00
WHEN IS COMMISSION PAID?
Commission will be paid on the 15th each month for all receipts during the previous month.
Example :
All commissions relating to policy premiums received during January (1 Jan – 31 Jan) will be paid on 15 February or the first working day there after in the event that the 15th falls over a weekend.
WILL WE GET COMMISSION STATEMENTS?
Exclusion
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Members can submit their claim online and upload the supporting documentation at Cinagi Claim Form. Members will be guided as to what supporting documents are required.
OUR POLICY AND EXCLUSIONS
Our policy includes certain exclusions to protect against unnecessary losses and ensure long-term sustainability.
We list below the most salient of the exclusion types but encourage you to familiarise yourself with the full list of exclusions contained in Section D of the policy document :
- CLAIMS NOT COVERED BY THE MEDICAL SCHEME – in line with the demarcation regulations, a gap cover policy may not cover any claim for treatment that is excluded by a medical scheme.
- EX-GRATIA CLAIMS – any claims that are paid by a medical scheme on an ex-gratia or concessionary basis are excluded.(excl Oncology Ex-Gratia Benefit)
- DAY-TO-DAY CLAIMS – unless shown as a specific benefit in the benefit table, day-to-day claims are not covered.
- CO-PAYMENTS APPLIED AS A PERCENTAGE – under the ‘Upfront Payments’ category of gap cover benefits, any upfront payments, co-payments or deductibles that are applied against the scheme benefits as a percentage of costs are limited to a maximum benefit of R12,000 on GapCORE and R18,000 on GapMAX per event. Only upfront payments, co-payments or deductibles that are defined in rand value within the medical scheme rules are covered in full.
- PENALTY AMOUNTS – any amount required to be paid by a medical scheme member for non-adherence to the scheme’s rules or pre-authorisation procedures are excluded from cover.
- SPECIALISED IN-HOSPITAL DENTISTRY – claims for bridges, implants, crowns, orthognathic surgery, frenectomies are excluded. This does not apply to basic in-hospital dentistry, eg fillings for young children, surgical wisdom teeth extraction.
- UNAPPROVED TREATMENT – Any claim excluded by your medical scheme or where the hospital admission or treatment was not approved by your medical scheme.
- PROVEN EFFICACY – Any claim for which your medical scheme has limited the benefit or imposed co-payments because the scheme does not recognise the clinical efficacy or validity of the related procedure or treatment.
- WEIGHT LOSS – Any claim relating to weight-loss treatment or bariatric surgery.
- LATE CLAIMS – Any claim submitted more than 4 months after date of treatment.
- UNREGISTERED TREATMENTS – any experimental, unproven or unregistered treatments, medicines or practices are excluded from cover.
- TERRITORY – Any claim arising from an event that occurred outside of South Africa (excl Travel Cover).
- CASUALTY COVER – applies only to care received at an out-patient casualty facility within 12 hours of an accident. The
benefit excludes claims for appliances, materials, prosthetics, specialised radiology and any subsequent treatment after
the initial visit to the casualty facility. - SPORTS COVER – is provided subsequent to a Casualty Cover claim where the event that gave rise to the claim occurred
during a sports activity (can be social activity or part of an organised event). The benefit is limited to one event annually
and covers up to 6 physiotherapy or chiropractic consultations within 6 weeks of the accident.
New Business
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Members can submit their claim online and upload the supporting documentation at Cinagi Claim Form. Members will be guided as to what supporting documents are required.
HOW TO GET A NEW BUSINESS QUOTE
We would like to offer you and your client the best premiums possible. In order to do so we do an risk assessment of the demographic profile of your client.
To do this risk assessment we require that you submit various demographics for each eligible member, this includes :
- Date of Birth or Age of principal member
- Medical Scheme
- Medical Scheme Benefit Option
- Number of Spouse Dependents
- Number of Child Dependents
This information can be sent to : quotes@cinagi.co.za
HOW CAN A NEW MEMBER JOIN?
Whether a member is a private individual or part of an employer group, they can join by making use of the Cinagi Online Application :
HOW CAN A NEW EMPLOYER GROUP JOIN?
HOW ARE PREMIUMS CALCULATED FOR PRIVATE INDIVIDUALS
Medical Second Opinion
Click here if you would like to find out more about Medical Second Opinion.
Monthly Employer Billing
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Members can submit their claim online and upload the supporting documentation at Cinagi Claim Form. Members will be guided as to what supporting documents are required.
HOW DO NEW EMPLOYEES JOIN AS PART OF A EMPLOYER GROUP?
An employee wishing to join the group scheme can do so by completing the online application.
When completing the application the employee will be asked to complete the details of his employer which will allow us to allocate accordingly.
WHAT ARE THE CUT OFF DATES FOR NEW APPLICATIONS?
The inception date of the employee’s membership on the group scheme will depend on the date that the employee completes the application form, as follows:
Employee Submits Application: | Inception Date |
On or before the 14th day of a month | The 1st of the same month |
After the 14th day of a month | The 1st of the following month |
Membership can only commence on the 1st day of a month. |
HOW DOES THE BILLING PROCESS WORK?
Cinagi will issue a listing by the 15th of each month showing which members are covered under the group scheme.
We then require confirmation that the member listing provided is correct or an indication on the attached spreadsheet of any resignations.
New additions to the group scheme are managed through the online application form (as per section 1 above) – if the application form was completed by an employee on or before the 14th of the month, then they will appear on the member listing that we issue for that month.
If the member completes the application form after the 14th of the month, then they will only be permitted to join from the 1st of the following month.
The updated spreadsheet must please be returned to billing@cinagi.co.za by reply on the e-mail we sent on the 15th – this needs to reach us by no later than the 24th of the month.
Note : Subject line of this e-mail is not to be changed as it contains a reference code to link to your account to our systems.
We will then issue the billing statement on the 27th of that month.
WHAT PAYMENT REFERENCE AND BANKING DETAILS DOES THE EMPLOYER USE?
On receipt of the employer application and subsequent activation a Welcome letter will be issued directly to the employed containing the payment reference along with the detailed billing process.
Also attached to the Welcome Letter will be the banking details of Infiniti Insurance Ltd. This can also be downloaded here.
Policy Servicing
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Members can submit their claim online and upload the supporting documentation at Cinagi Claim Form. Members will be guided as to what supporting documents are required.
GET IN TOUCH WITH US THROUGH THESE CHANNELS
All existing policy holders can get in touch with us through any of the below channels :
- WhatsApp Text Messenger (060 070 2310): When sending a message, the Cinagi client service bot will first try and assist for basic queries. Should the bot not be able to provide the necessary assistance, the conversation will be routed to one of our service consultants.
- Schedule-a-call : Should a member prefer to speak directly with one of our service consultants, they can schedule a call at a convenient time by make use of our Call Scheduler. This allows us to do all the necessary screening and preparations beforehand, which allows us to provide each member with the best possible service at point of engagement.
- Contact Page : All queries logged though our contact page will be routed accordingly based on the nature of the query. On submission the member will receive a confirmation email.
Underwriting and waiting periods
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Members can submit their claim online and upload the supporting documentation at Cinagi Claim Form. Members will be guided as to what supporting documents are required.
WHY DOES CINAGI UNDERWRITE AND/OR APPLY WAITING PERIODS?
Appropriate and accurate underwriting are important in order to manage anti-selection risks that the insurer faces as well as
to be fair to the existing members in the risk pool.
HOW DO YOU UNDERWRITE?
Three underwriting questions are included within the membership application. It is important to advise prospective clients of the importance of answering these as accurately and honestly as possible to avoid possible claim rejections or policy cancellations.
HOW DO WAITING PERIODS WORK?
The application of waiting periods on the gap cover benefits of the policy is guided by regulations.
A 3-month general waiting period and a 12-month condition-specific waiting period is permissible.
- The 3-month waiting period applies to all gap cover benefits, excluding claims arising from accidental events. The Cancer Diagnosis and Travel Cover benefits also have a 3-month waiting period.
- The 12-month waiting period applies to any condition for which medical advice, diagnosis, care or treatment was
recommended to or received by an insured within a period of 12 months before entering into the policy.
WHEN ARE WAITING PERIODS APPLIED?
- NEW MEMBERS ON VOLUNTARY GROUPS AND PRIVATE INDIVIDUALS
Both the 3-month general waiting period and 12-month condition specific waiting period will always be applied to
these categories of members unless proof of previous cover can be provided.For more information on how waiting periods are applied to members who had previous cover see section “Waiting Periods for members with previous cover”
- EXISTING VOLUNTARY GROUPS TRANSFERRING
For a group size of at least 25 members, all waiting periods will be waived for this category of members - COMPULSARY GROUPS
For a group size of at least 25 members, all waiting periods will be waived for this category of members.Waiting periods will also be waived for new members joining the compulsory group when they become eligible to join.
Note
This will only apply to groups where Cinagi is the only gap cover provider to that employer – if the employer creates a split-risk arrangement by making another gap cover provider available to their staff, Cinagi reserves the right to impose waiting periods on future members joining such a group.
- CONTINUATION MEMBERS
If an employee is part of a group scheme arrangement with waived or reduced waiting periods and resigns from the group and wishes to continue with cover, they will be required to complete a new Cinagi online application and select option 4 under ‘Application Status’ at the top of page 2.This application as a private individual will then be re-assessed by our underwriting team, taking into account the previous duration of cover under the group scheme. The new policy premium will also be rated according to the table applicable to private individuals.
Cinagi further reserves the right to impose a 3 month general waiting period on such policies based on our underwriting criteria.
- WAITING PERIODS FOR MEMBERS WITH PREVIOUS COVER
If a member is joining from another gap cover provider and does so within 90 days of the previous cover ceasing, the balance of any unexpired portion of the 12-month waiting may be applied.If the member had been on the previous cover for more than a year, then no portion of the 12-month waiting period will be applied.
It is important to note though, that this only applies if the previous gap cover policy had benefits that were materially similar to Cinagi Gap Cover benefits. If the previous gap cover benefits were not materially similar, then the full 12-month waiting period may be applied.
Cinagi further reserves the right to impose a 3 month general waiting period on such policies based on our underwriting criteria.
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At Cinagi, we are committed to excellence. Our many years of experience in the healthcare industry, combined with excellent service levels gives you the peace of mind that you have the best health insurance cover available.
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