Gap Cover
Providing a wide range of extensive Gap Cover benefits, each carefully designed to cater to every Medical Scheme option. This is paired with our unparalleled, individualised service delivery, ensuring a personalised and effective healthcare experience for all policy holders.
Gap Cover – Quick Summary
| Benefit category | Gap cover benefit description | 2027 benefit amounts & limits |
|---|---|---|
| Overall annual limit (OAL) per insured person * | R226,800 | |
| Tariff shortfalls | We cover:
|
Total Cover EnhancementSubject to OAL |
| We cover gynaecologist and/or paediatrician consultations from the 2nd trimester to 90 days post-delivery | R760 per consultationR3,100 per pregnancy | |
| Oncology co-payments # | We cover the 20% co-payment applied after reaching the oncology threshold | 100% cover |
| We cover co-payments on approved precision medicines | R25,000 per claim | |
| We cover co-payments applied on ex-gratia benefits for precision medicines | R25,000 per claim | |
| Upfront payments | We cover fixed rand value upfront payments for MRI/CT/PET scans, in-hospital endoscopes, in-hospital basic dentistry and defined medical procedures | 100% cover |
| We cover other upfront payments (including robotic surgery) | R29,000 per event | |
| We cover upfront payments for voluntary use of a non-network hospital or clinic | R22,000 per eventMax 2 per annum | |
| Limit extender | We cover shortfalls when a sub-limit applies to internal prosthetic devices | R73,000 per event |
| We cover shortfalls when a sub-limit applies to MRI/CT/PET scans, endoscopes and intra-ocular lenses | R9,200 per event | |
- For all Gap Cover benefits, claims can only be paid where a shortfall exists between the medical scheme benefit and the charged amount.
- * The statutory overall annual limit (OAL) for all Gap Cover benefits. This limit will automatically increase from 1 April 2027 in line with CPI.
- # All oncology cover categories include treatment using new generation biologicals/immunotherapies (i.e. precision medicines).
- Unless specified otherwise, benefit categories are subject to the Overall Annual Limit.
Extender Cover – Quick Summary
| Benefit category | Extender cover benefit description | 2027 benefit amounts & limits |
|---|---|---|
| Casualty cover | We cover emergency treatment:
|
Accident R20,000 per eventChild illness R3,800 per eventMax 3 per policy per annum |
| If the accident was a sports injury, we also cover shortfalls on rehabilitation consultations at a physiotherapist, biokineticist or chiropractor | R850 per consultMax 6 per event | |
| Travelling abroad | We cover the excess on your international travel insurance for medical emergencies | R4,200 per departure |
| Cancer diagnosis | We pay a once-off lump sum on a first lifetime diagnosis ‡ | Stage 1 R7,000Stage 2 R20,000Stage 3 R30,000Stage 4 R50,000 |
| If after diagnosis you upgrade your medical scheme benefit option at the first opportunity, we provide a waiver for the additional medical scheme contributions ** | R5,600 per monthUp to 12 months | |
| Extra cover | For an admission resulting from an accident where the admission is 3 days or longer, we pay a daily lump sum: Tier 1 from day 1 to 7 and Tier 2 from day 8 to 28 | Tier 1 R180 per dayTier 2 R1,800 per day |
| We pay a lump sum for a birth that is 42 days or more premature | R22,000 per event | |
| Accident cover | In the event of accidental death or permanent disability caused by an accident. If the event is a direct result of a proven crime, the benefit doubles ¥ | R36,000 |
| Waiver cover | In the event of accidental death or permanent disability of the principal member or spouse, we cover the medical scheme contributions and gap cover premiums for 6 months | R8,600 per month – medical aid100% of gap policy premium |
| Trauma cover | If an insured is a witness to or a victim of a violent crime, we cover sessions with a counselling therapist | R1,000 per sessionMax R11,000 per policy per annum |
- ‡ Skin cancer is excluded (except melanomas of stage 2 or more) and the benefit ceases at age 65. To qualify as a first lifetime diagnosis there must have been no previous form of cancer, including skin and in-situ.
- ** If no upgrade is undertaken, no benefit is payable. To qualify, the upgrade must be to the richest benefit option on the scheme or another option agreed by Cinagi. If the member downgrades within 12 months of upgrading, the monthly benefit ceases at the time of the downgrade. Upgrading is subject to the rules of the medical scheme.
- ¥ Maximum of 2 insured persons per event.
Your monthly COSTS explained
For private individuals, Cinagi benefit costs are structured on the entry age of the oldest person joining the policy as well as the family size. Our integrated Cover Pay Level (CPL) structure also recognises if you are on a richer medical scheme benefit option. If your benefit option covers medical specialists for in-hospital treatment at 200% or more of scheme tariff, then the CPL-200 benefit costs will apply to your cover. If the in-hospital medical specialist cover is at 100% of scheme tariff, then the CPL-100 benefit costs will apply.
GapMAX · Private individuals · Monthly rates from 1 January 2027
| Entry age | Principal | Adult | Child |
|---|---|---|---|
| Under 30 | R288 | R199 | R91 |
| 30 – 39 | R304 | R211 | R91 |
| 40 – 49 | R334 | R238 | R91 |
| 50 – 64 | R430 | R321 | R91 |
| 65+ | R906 | R644 | R91 |
| Entry age | Principal | Adult | Child |
|---|---|---|---|
| Under 30 | R367 | R254 | R127 |
| 30 – 39 | R388 | R277 | R127 |
| 40 – 49 | R412 | R298 | R127 |
| 50 – 64 | R595 | R425 | R127 |
| 65+ | R1,069 | R759 | R127 |
Important notes
- The Cover Pay Level (CPL) is the percentage of the medical scheme tariff at which your benefit option covers in-hospital medical specialists. Your monthly costs and benefit calculations depend on the CPL.
- Only your spouse and/or children are eligible as dependants on this policy, and you must all be covered under the same medical scheme membership.
- You or your spouse can be the principal member on your Cinagi policy. A spouse dependant is charged the adult rate.
- Child dependants are charged child rates until they turn 27, and a maximum of two children are charged per family. From 27 years all children are charged adult rates.
- The Entry Age category is determined by the oldest person covered under your policy.
- Rates include VAT, broker commission and administration fees, as well as the fee for Wellniciti Savings, which is automatically included in all Cinagi products.
- Rates are adjusted on 1 January each year in line with medical inflation.
- Debit orders are deducted in advance on the 1st working day of each month.
Features
In-Hospital Cover
Comprehensive protection against shortfalls in your medical scheme cover for medical specialists and surgeons.
Oncology Cover
Our oncology cover offers you the most comprehensive industry-leading protection against oncology co-payments and tariff shortfalls.
Casualty Cover
Provides cover for emergency treatment at a casualty facility for accidents plus an additional rehabilitation benefit for sports injuries.
Upfront Payments
Full cover for upfront payments or deductibles on diagnostics and surgical procedures.
Financial Soundness
All Cinagi insurance products are underwritten by our exclusive business partner, Infiniti Insurance Ltd, an A credit rated underwriter.
Affordable Monthly Cost
Starting at just R288 for GapMAX, you get industry leading protection at competitive costs.
Travel Cover
We will cover the excess payable on your travel insurance policy for claims on medical emergencies whilst traveling internationally.
Claim Optimiser
Don’t be out of pocket – our Claim Optimiser will guarantee upfront payments to providers, meaning no out-of-pocket costs for you.
Wellniciti Savings
Cinagi’s wellness and financial rewards programme, offering discounts on primary care healthcare providers, everyday grocery items at our selected retail partner and personal financial coaching to assist with improved financial wellbeing.
Visit www.wellniciti.co.za/savings for more details.
Instaclaim – South Africas First “60-Minute” Gap Cover Claims Process
Groundbreaking innovation in the insurance industry where qualifying gap cover claims are paid within 60 minutes of submission.
Your Cover Explained
Gap Cover
Specialist Cover
If you are admitted to hospital or receive care for approved oncology treatment, your medical scheme may only refund you a portion of what your specialists and surgeons charge for their services. When this happens, we provide additional cover to pay for these shortfalls.
Oncology Co-payment Cover
We cover 3 categories of oncology shortfalls, all including modern biologicals and immunotherapies (precision medicines) approved by your medical scheme:
- The 20% co-payment applied on all oncology costs
- The 25% or 50% co-payments applied on Precision Cancer Medicines
- Co-payments applied to precision medicines approved as an ex-gratia benefit by your medical scheme
Upfront Payments
If your medical scheme has fixed-value upfront payments on MRI/CT/PET scans, in-hospital endoscopes, in-hospital basic dentistry or defined approved surgical procedures, we cover these in full. We also cover co-payments applied as a percentage of medical costs and where you voluntarily use a non-network hospital or day clinic.
Limit Extender
Should your medical scheme impose a rand limit on internal prosthetic devices (e.g. joint replacements, spinal fusions, pacemakers), we provide additional cover per procedure. Additional cover is also provided for sub-limits on MRI/CT/PET scans, endoscopes and lens implants.
Maternity Cover
We cover tariff shortfalls on consultations with a gynaecologist during the 2nd and 3rd trimester, and gynaecologist or paediatrician consultations up to 90 days after birth.
Extender Cover
Casualty & Sports Cover
For an emergency caused by an accident, we cover x-rays, blood tests, medicines and fees of attending doctors at a casualty facility. If the treatment was the result of a sports accident, we also cover shortfalls on follow-up rehabilitation consultations for physiotherapy or chiropractic treatment.
Travel Cover
Covers the excess payable on your international travel insurance for medical emergencies while travelling outside the country.
Cancer Diagnosis
If you receive a first lifetime diagnosis after joining and expiry of all waiting periods, we pay a once-off lump sum to assist with associated non-medical costs. We also cover the additional medical scheme contributions if you upgrade your medical scheme option.
Extra Cover
If you are admitted to hospital for 3 days or more after an accident, we pay you a lump sum per day for up to 28 days. If your baby is born 42 days or more before the expected due date, we pay a lump sum.
Accident Cover & Waiver Protector
A lump sum is payable on the accidental death or permanent disability of an insured – if caused by crime, the benefit doubles. The Waiver Protector pays your medical scheme contributions and gap cover premiums for 6 months on the accidental death or permanent disability of the main member or spouse.
Wellniciti – Included With Your Cover
Wellniciti is Cinagi’s wellness and financial rewards programme, available exclusively to Cinagi clients. The cost of Wellniciti is automatically included in your total monthly Cinagi benefit cost. Learn more about Wellniciti.
Savings on Healthcare
Reduced consultation fees on a wide range of primary healthcare providers. Visit www.wellniciti.co.za, click “Access Your Savings”, log in with your ID number and choose “Book a Virtual Consult” or “Find a Healthcare Professional”.
Savings on Groceries
Save hundreds every month on everyday groceries at Shoprite, Checkers and Checkers Hyper. Get your savings coupons via WhatsApp on 065 753 1916 (option 2) or at www.wellniciti.co.za and present them at the till before you pay. Savings apply over and above in-store promotions.
Financial Wellbeing
Confidential one-on-one telephonic coaching on budgeting, debt management, credit health, buying a home or vehicle, drafting a will, tax queries, saving and retirement planning.
Member Service Portal
To ensure efficient, quick and user-friendly client servicing, Cinagi has developed a bespoke digital member portal for all clients.
Submit a Claim
Claiming is a quick and simple online process. You will need:
- The relevant account from the doctor or provider
- The claims statement from your medical scheme showing how they processed and paid the account (downloadable from your scheme’s website or portal)
- For a hospital admission, the first 2–3 pages of the hospital account showing admission/discharge dates, ICD-10 codes and patient name
Update Your Details
Update your contact details, debit order details, medical scheme cover and add or remove policy dependants.
Get a Copy of Your Policy
Download a copy of your policy document and/or a confirmation of your cover.
Claim Optimiser – Direct Payment
If you are required to pay an upfront payment before being admitted to hospital, our Claim Optimiser guarantees the payment directly to the hospital, so you do not need to make any out-of-pocket payment.
This service is not available while your policy is subject to a waiting period, and you need to contact us at least 72 hours before your admission to activate it.
InstaClaim – South Africa’s First “60-Minute” Gap Cover Claims Process
InstaClaim is our fully digital, AI-powered claims service that makes it possible for qualifying claims to be processed in under 60 minutes and paid instantly into your bank account. It is 100% digital with no paperwork, giving almost immediate refunds to clients who have already paid upfront for medical expenses.
Together, Claim Optimiser and InstaClaim aim to ensure that you are never out of pocket when it comes to medical claims.
Terms, Conditions & Exclusions
Monthly benefit cost
- If you add beneficiaries to your medical scheme you must notify us immediately to ensure that they are registered on your policy.
- You and your dependants registered on your medical scheme or your spouse’s medical scheme (or both where applicable) are covered under this policy.
- Once a dependant comes off your or your spouse’s medical scheme membership, they are no longer covered under this policy (they may apply for their own Cinagi policy).
- Wellniciti Savings is a separate loyalty product sold and administered by Cinagi – visit www.wellniciti.co.za/savings for details. The monthly benefit cost on your member schedule includes the Wellniciti fee.
- The information and services provided by the Financial Wellbeing component of Wellniciti are for educational and informational purposes only and do not constitute financial, investment or professional advice.
Waiting periods
- A 3-month general waiting period applies on all claims except for accidents.
- A 12-month waiting period applies on all claims directly or indirectly related to the treatment of scopes (including minimally invasive scopes, endoscopies, arthroscopies and hysteroscopies), endometrial ablations, hysterectomy, pregnancy and childbirth, cholecystectomy, wisdom teeth, dental treatment, cataracts, reflux surgery, tonsillectomy, grommets, adenoidectomy, nasal procedures, hernia procedures, joint replacements and spinal surgery.
- A 12-month waiting period applies on any claims relating directly or indirectly to any pre-existing medical condition you or your dependants had at policy inception, or any advice, diagnosis, care or treatment received or recommended within the 12 months before policy inception.
- Waiting periods apply to new dependants added to your policy after inception.
- If you previously had a gap cover policy with similar benefits and there were less than 90 days between ending that policy and starting with us, a 3-month general waiting period and/or the unexpired portion of any previous 12-month waiting period will apply.
- Waiting periods for corporate groups may be waived or reduced based on eligibility criteria – please refer to your Policy Schedule.
Gap cover exclusions
- Gap cover can only cover shortfalls on medical costs. Where a medical scheme excludes treatment, gap cover cannot provide any cover.
- 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 procedure or treatment.
- Any claim for specialised dentistry or elective maxillofacial surgery, e.g. bridges, implants, frenectomy, orthognathic surgery (this does not apply to basic in-hospital dentistry such as wisdom teeth extractions or fillings for young children).
- Any co-payment, deductible or limitation applied as a penalty for non-adherence to medical scheme rules or voluntary use of a non-network provider.
- Any claim relating to weight-loss or bariatric surgery, obesity (including related modifier codes), infertility and sleep studies.
- Any claim submitted more than 4 months after the date of treatment.
- Claims not recognised as medically necessary or paid as an ex-gratia / concession.
- Experimental, unproven or unregistered treatments, medicines or practices.
- Any claim incurred outside of South Africa (excluding Travel Cover).
- Any claim arising from a medical service provider and/or medical scheme not complying with prevailing legislation.
- Shortfalls on hospital accounts, day clinics, step-down facilities or diagnostic services (pathology and radiology), other than co-payments/upfront payments shown on the benefit schedule.
- Casualty Accident Cover applies only to emergency treatment at a casualty facility within 12 hours of an accident, and excludes appliances, prosthetics and any subsequent treatment after the initial visit.
- Casualty Illness Child Cover applies only to emergency treatment for a child younger than 12 at a casualty facility after hours (Mon–Fri between 6pm and 6am, plus weekends and public holidays), and excludes appliances, prosthetics and any subsequent treatment after the initial visit.
This policy is not a medical scheme and the cover is not the same as that of a medical scheme. This policy is not a substitute for medical scheme membership. This page is a summary of Cinagi GapMAX – please read the policy document for full details or contact us for more information. Cinagi (Pty) Ltd is an authorised financial services provider (FSP 50104). Gap cover is underwritten by Infiniti Insurance Limited, a licensed non-life insurer and an authorised financial services provider (FSP 35914).
Joining is Easy
Contact us form more information or speak to your healthcare advisor today about Cinagi Gap Cover.
Joining online is easy and you can have your cover in place in under 15 minutes!
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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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