Medical scheme exclusions stated benefit limits, and any claims or claim portions rejected, or not authorised by your medical scheme, unless the benefits fall within the stated benefit entitlement as per this policy wording of the Ultimate Gap Cover benefits.
If your medical aid does not provide cover for a procedure or the benefit for the procedure have been used up and there is nothing left in the benefit to pay towards each procedure code this claim will fall within this policy exclusion.
Sirago cannot take the place of a medical aid, and therefore cannot provide cover for procedures and/or procedure codes not covered by the medical aid.
Nikita went for a specialist consultation, however her medical aid did not cover their scheme rate / tariff code. As the medical aid did not pay anything towards the specialist consultation fee code because the client ran out of savings for the year; Nikita cannot claim for the consultation fee from Sirago.
Bridget went for a scope in the doctor’s room, where they performed a gastroscopy. Bridget received her medical aid statement that reflected a charged amount for the provider writing out a script. This was rejected by the scheme in full, which was then also rejected by Sirago as it is excluded on her scheme and no payment was made towards that specific tariff / procedure code.
Things to consider when receiving this repudiation reason:
This repudiation will be valid where the medical aid has rejected the tariff code (procedure code) / account or part of the account for one of the following reasons:
- This is a scheme exclusion / There is no benefit for this
- There is no cover for this procedure on your option
- Your savings are depleted / you have no medical savings
- You have reached your medical scheme threshold