Gap Cover

2023

Your journey to quality healthcare starts here.

Features of Bloom Gap Cover

•

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 benet for sports injuries

•

UPFRONT PAYMENTS

Full cover for upfront payments or deductibles on diagnostic and surgical procedures

•

AFFORDABLE PREMIUMS

Starting at just R217 for Gap

MAX

and R188 for Gap

CORE

, you get industry leading protection at competitive premiums

•

MEDICAL SECOND OPINION

When serious illness strikes you have access to a second opinion from the world’s leading medical minds to make sure you have the right

diagnosis and treatment plan

•

TRAVEL COVER

We will cover the excess payable on your travel insurance policy for claims on medical emergencies whilst travelling 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

Although you and your family have medical scheme cover, unexpected medical costs can arise when your medical

scheme only refunds you a portion of what your doctors have charged you for treatment.

Bloom Gap Cover is the industry leading solution giving you comprehensive nancial protection against these unforeseen

medical costs.

This policy is not a medical scheme and the cover is not the same as a medical scheme.

This policy is not a substitute for medical scheme membership.

Bloom Gap 2023 I Underwritten by Infiniti Insurance Limited, a licensed non-life insurer and an authorised financial services provider (FSP No.35914).

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Your Gap Cover A QUICK SUMMARY

Benet

Category

Extender Cover Benet Description

Benet Amounts and Limits

Gap

MAX

Gap

CORE

Casualty

Cover

Cover for emergency treatment at a casualty facility resulting from an accident R18,000 per event | max 2 pa R14,000 per event | max 2 pa

If the accident was a sports injury, we will also cover shortfalls on rehabilitation consultations R680 per consult | max 6 pe R460 per consult | max 6 pe

Travel

Cover

Cover for the excess on your international travel insurance for medical emergencies R3,400 per departure R2,400 per departure

Cancer

Diagnosis

For a rst lifetime cancer diagnosis made after inception of the policy and waiting periods

‡

R40,000 Lump Sum R30,000 Lump Sum

If after diagnosis you upgrade your medical scheme benet option at the rst upgrade

opportunity, we will provide a waiver for the additional contributions

R4,000 pm for 12 Months R4,000 pm for 12 Months

Extra Cover

For an admission resulting from an accident and where the admission is 3 days or longer

Daily Lump Sum Payable: Tier 1 pays from day 1 to 7 and Tier 2 pays from day 8 to 28

Tier 1 = R160 per day

Tier 2 = R1,600 per day

Tier 1 = R110 per day

Tier 2 = R1,100 per day

For a premature Birth that is 42 Days or more earlier than the expected due date R20,000 per event R15,000 per event

Accident

Cover

In the event of accidental death or permanent disability caused by an accident

If the event was a direct result of a proven crime, an additional benet is payable

R32,000 pppa

R28,000 pppa

Waiver

Cover

In the event of accidental death or permanent disability of the principal member or spouse, we

will cover the cost of the medical scheme contributions and gap cover premiums

R7,800 pm - medical aid

100% on policy

R5,400 pm - medical aid

100% on policy

‡

- Applies to a cancer diagnosis of stage 2 or higher – skin cancers are excluded except melanomas – benet ceases at age 65 |

- If no upgrade is undertaken, no

benet is payable. The upgrade must be to the richest benet option on the scheme or other benet option agreed to with the underwriter. If the member downgrades

within 12 months of upgrading, the monthly benet ceases at the time of the downgrade. Upgrading is subject to the rules of the medical scheme |

- Limited to a

maximum benet for two insureds per event |

Your Extender Cover A QUICK SUMMARY

Bloom Gap 2023 I Underwritten by Infiniti Insurance Limited, a licensed non-life insurer and an authorised financial services provider (FSP No.35914).

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Your Cover EXPLAINED

GAP COVER

SPECIALIST COVER

If you are admied to hospital or receive care for approved oncology

treatment, your medical scheme may only refund you a poron of what

your specialists and surgeons charge for their services. When this happens,

we will provide addional cover to pay for these shoralls

ONCOLOGY CO-PAYMENT COVER

We cover 3 dierent categories of shorfor oncology. Across all 3

categories, we include cover for modern biological and precision drugs

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 medicines approved as an ex-graa benet

by your medical scheme

UPFRONT PAYMENTS

If your medical scheme has xed-value upfront payments on MRI/CT/

PET scans, in-hospital endoscopes, in-hospital basic denstry or dened

approved surgical procedures, we will cover these in full. We also provide

you with cover for co-payments applied as a percentage of medical costs

and where you voluntarily make use of a non-network hospital or day clinic

LIMIT PLUS

Should your medical scheme impose a rand limit on internal prosthec

devices (eg, joint replacements, spinal fusions, pacemakers, etc), we will

provide addional cover per procedure. Addional cover is also provided

for sub-limits on MRI/CT/PET scans, endoscopes and lens implants

MATERNITY COVER

We cover tari shoralls on consultaons with a gynaecologist or GP during the

2nd and 3rd trimester

EXTENDED COVER

CASUALTY COVER

For an emergency caused by an accident, we will cover you for x-rays,

blood tests, medicines and fees of aending doctors at a casualty facility

SPORTS COVER

If your treatment at a casualty facility was the result of a sports accident,

we will also cover shoralls on follow-up rehabilitaon consultaons for

physiotherapy or chiropracc treatment

TRAVEL COVER

Covers the excess payable on your internaonal travel insurance for

medical emergencies while travelling outside the country

CANCER DIAGNOSIS

If you are diagnosed with cancer (stage 2+) for the rst me aer joining,

we will pay you a once-o lump sum to assist with any associated non-

medical costs. We will also cover the cost of the addional medical scheme

contribuons if you upgrade your medical scheme opon

EXTRA COVER

If you are admied to hospital for 3 days or more aer an accident we will

pay you a lump sum per day for up to 28 days. If you have a baby that is

born 42 days or earlier than your original expected due date, we will pay

you a lump sum

ACCIDENT COVER

For accidental death/permanent disability of an insured a lump sum is

payable - if caused by crime the benet doubles

WAIVER PROTECTOR

Pays your medical scheme and gap cover for 6 months on accidental death/

permanent disability of main member or spouse

Bloom Gap 2023 I Underwritten by Infiniti Insurance Limited, a licensed non-life insurer and an authorised financial services provider (FSP No.35914).

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Mediguide serves millions of lives in more than 50 countries worldwide and is recognised

internationally as the world leader in their eld. For more information please visit www.

mediguide.com. If you are a Bloom member and wish to activate a MSO, please contact us on

www.cinagi.co.za/contact/

Medical Second Opinion (MSO) is an international service offering from our business partner,

Mediguide USA, that provides a potentially life-altering service by supporting you in making

the most informed decisions possible about your diagnosis and treatment options for serious

illnesses.

Diagnostic errors on serious illnesses occur more frequently than is readily acknowledged. This

is not unique to SA but an international phenomenon, recognised through several new scientic

studies.

MSO ensures that diagnostic mistakes are minimised, offering the best possible health outcome

for you and your family when major illness occurs.

Mediguide was established in 1997 and their global network of World Leading Medical Research

Centres (WLMRC) ensures that you can access the world’s leading medical minds for a second

opinion review when you are faced with a serious medical condition.

This potentially life-altering service is automatically available to all Bloom members. The

qualifying criteria to activate a review are as follows:

• Availability of a local and recent diagnosis

• You have served your policy’s 3 month waiting period (if applicable)

• The condition is not acute, requiring immediate treatment

• An in-person evaluation is not required (eg mental condition)

Once you have activated a MSO with us, a case manager will be assigned to you to assist in

collating all your relevant medical records and then uploading these to the WLMRC you have

chosen to have the MSO review done. Your results will then be reviewed and assessed by a multi-

disciplinary team at the WLMRC, where after they will provide you with a comprehensive written

report outlining any changes they have made to the initial diagnosis and their recommendation

on the best treatment plan.

You will then be free to either discuss this with your local physician or to consult with a new

physician - the choice will be up to you.

Your Medical Second OPINION EXPLAINED

Bloom Gap 2023 I Underwritten by Infiniti Insurance Limited, a licensed non-life insurer and an authorised financial services provider (FSP No.35914). Bloom Gap 2023 I Underwritten by Infiniti Insurance Limited, a licensed non-life insurer and an authorised financial services provider (FSP No.35914).

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Monthly Premiums

PRIVATE INDIVIDUALS - 1 JANUARY 2023

Use our easy online premium

calculator and join in less

than 3 minutes:

Click here

www.Bloom.co.za/get-a-quote

www.Bloom.co.za/applicaon-form

• The Cover Pay Level (CPL) is the percentage of the medical scheme

tariff level at which your benet option covers in-hospital medical

specialists. Your premium and benet calculations depend on the CPL

• Only your spouse and/or children are eligible as dependents 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 Bloom policy

• A spouse dependent will be charged adult premiums

• Child dependents will be charged child premiums until they turn 24

and a maximum of two children will be charged per family

• From 24 years all children are charged adult premiums

• The Entry Age category is determined by the oldest person covered

under your policy

• Premiums include VAT, broker commission and administration fees

• Premiums are adjusted on 1 January of each year in line with medical

ination

• Premiums are deducted in advance by debit order on the 1st working

day of each month

Important Notes

PRIVATE INDIVIDUALS Gap

MAX

Gap

CORE

Cover Entry Age Principal Adult Child Principal Adult Child

CPL-200

If your medical

scheme cover is

200%

< 30

217 142 60 188 123 52

30-39

229 157 60 199 136 52

40-49

249 175 60 216 152 52

50-64

309 229 60 268 199 52

65+

648 459 60 563 399 52

CPL-100

If your medical

scheme cover is

100%

< 30

278 190 91 241 165 79

30-39

289 204 91 251 177 79

40-49

305 219 91 265 190 79

50-64

426 305 91 370 265 79

65+

754 539 91 655 468 79

Your Monthly Premiums Explained

Bloom premiums 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 benet

option. If your benet option covers medical specialists for in-hospital treatment at 200% or more of scheme

tariff, then the CPL-200 premiums will apply to your cover. If the in-hospital medical specialist cover is at 100%

of scheme tariff, then the CPL-100 premiums will apply.

insurer and an authorised financial services provider (FSP No.35914).

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Member Portal

For queries relating to premiums or benets, contact Bloom on:

087 688 2500 | customer[email protected]

All other query types are handled by your policy administrator, Cinagi. For these queries, such as submitting claims, or using the claim optimiser or policy

queries, please use the Cinagi member portal. To access the Cinagi portal, please click here.

Through this member portal you can undertake the following administrative services:

SUBMIT A CLAIM – Claiming is a quick and simple online process. You will require the following information/documents to submit your claim:

• The relevant account from the doctor or provider

• The claims statement from the medical scheme showing how they have processed and paid for the above account – this can be downloaded from your

medical scheme’s website/portal

• If you claim relates to a hospital admission, we will need the rst 2-3 pages of the hospital account showing the admission/discharge dates, ICD-10

codes, patient name, etc

CLAIM OPTIMISER – if you are required to pay an upfront payment before being admitted to hospital, we have developed the Claim Optimiser, which

guarantees the payment directly to the hospital. This means that you do not need to make any out-of-pocket payments and we will pay the provider

directly on your behalf. Please note that this service is not available if your policy is still subject to a waiting period and you will need to contact us at least

72 hours before your admission to activate the Claim Optimiser.

UPDATE YOUR DETAILS – you can update any of your personal details here such as contact details, debit order details, your medical scheme cover and

the addition/removal of policy dependants.

UPGRADE YOUR GAP COVER POLICY – if you are on the Gap

CORE

policy, you can upgrade to the Gap

MAX

policy which provides you with enhanced cover.

GET A COPY OF YOUR POLICY – you can download a copy of your policy document and/or a conrmation of your cover with us.

Please visit www.cinagi/co.za/contact/ to Access Our Digital Contact Channels

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Our Terms & Conditions Explained

MONTHLY PREMIUMS

• If you change medical schemes or upgrade/downgrade your benet option, you must notify us immediately to ensure that you are on the correct Cover Pay Level. Your

premium may change depending on your new Cover Pay Level

• If you add beneciaries to your medical scheme you must notify us immediately to ensure that they are registered and that the correct premiums are applied

• The Entry Age Category is based on the oldest person on your policy at the time of inception - once on cover you remain in the same category

• If you later add a dependent to your policy that is in an Entry Age Category that is higher than the current Entry Age Category, then the new Entry Age Category will

apply to the policy from the date that the new dependent is added

• A maximum of two children will be charged per policy until they are 24 years old

• Adult premiums will apply to all child dependents from age 24 onwards – the higher premium will automatically apply from the month after they turn 24

• To qualify for benets under this policy, you and your dependants must be registered on the same medical scheme membership where either you

or your spouse are the principal member

• Once any dependent on your policy comes off either your or your spouse’s medical scheme membership, they will no longer be

covered under this policy (they have the option of applying for their own Bloom policy at such stage)

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 (which include minimally invasive

scopes, endoscopies, arthroscopies and hysteroscopies), endometrial

ablations, hysterectomy, pregnancy and childbirth, cholecystectomy,

wisdom teeth, dental treatment, cataracts, reux 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 any of your dependants

had at the policy inception, or

- Any advice, diagnosis, care or treatment you or any or your

dependants received or was recommended to receive within the

12 month period prior to the policy inception

• Waiting periods apply to new dependents added to your policy after

inception

• If you previously had a gap cover policy with similar benets, with

less than 90 days between the time you ended that policy and

activated your policy with us, a 3-month general waiting period and/

or the unexpired portion of any previous 12-month waiting period will

apply

insurer and an authorised financial services provider (FSP No.35914).

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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 benet or imposed

co-payments because the scheme does not recognise the clinical efcacy or

validity of the related procedure or treatment

• Any claim for specialised dentistry or elective maxillofacial surgery, eg

bridges, implants, frenectomy, orthognathic surgery, etc. (This does not

apply to basic in-hospital dentistry, such as wisdom teeth extractions or

llings for young children)

• Any co-payment, deductible or limitation applied to the medical scheme

benets as a penalty for non-adherence to the medical scheme rules or

voluntary use of a non-network provider

• Any claim relating to weight-loss or bariatric surgery

• Any claim submitted more than 4 months after 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 that is incurred outside of South Africa (excl Travel Cover)

• Casualty Cover applies only to care at a casualty facility within 12 hours of an

accident, and excludes appliances, prosthetics, specialised radiology and any

subsequent treatment after the initial visit to the casualty facility.

• Shortfalls on hospital accounts, day clinics, step-down facilities or diagnostic

services (pathology and radiology), other than co-payments/upfront

payments shown on the benet schedule

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 brochure is a summary of Bloom Gap Cover – please read the policy document for

full details or visit www.Bloom.co.za for more information.

Bloom Gap 2023 I Underwritten by Infiniti Insurance Limited, a licensed non-life insurer and an authorised financial services provider (FSP No.35914).

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Website: https://bloom.insure I Email Address: customer.services@bloom.insure I Call Number: 087 688 2500

Underwrien by Inni Insurance Limited a licensed non-life insurer and an authorised nancial services provider (FSP No.35914).