Talksure Ambledown gap cover is useless!!!

Dear Malisha R,

I thank you for co-operation and assistance thus far,  I update you as follows: 

I record the following on the claims assessed on your policy:

• One claim was paid and three rejected.
• Of the rejected claims, One claim relates to a benefit you do not have on the policy and the other two are for outpatient treatment, "an undefined event".

The product is not designed to pay for all forms of costs that are not covered by the medical aid scheme. It is not designed to replace a medical aid scheme and is not designed to cover costs that should be carried by a medical aid scheme, e.g. Medicines, materials, hospital expenses, PMB claims, day to day consultations, treatment and or procedures performed in doctor’s rooms. 1. Generally treatment will be covered if it meets the defined event conditions below:  DEFINED EVENTS In the event of an Insured Person suffering an insured incident (as defined) which necessitates the Insured Person: ·         Being confined to hospital and·         The necessity for outpatient treatment for the following procedures: please refer to list in your policy document The main policy benefit is extracted below as:  Gap Cover - A benefit equal to actual cost limited to five (5) times the Medical Scheme Tariff less the higher of the Medical Scheme Tariff or Medical Scheme Option Reimbur*****t Rate for treatment received whilst as an in-patient and/or outpatient (as stated in the Defined Event). As you could see from the policy wording extractions, you had to be confined to hospital  or would have received outpatient treatment as per the pre-defined list for one of the procedures outlined in your policy schedule
2. Claims are further assessed based on policy benefits, terms and conditions. Regrettably your policy does not have a co-payment benefit and was therefore rejected as per the General exception. “Co-Payment” means a stated amount imposed as a co-payment or deductible by a medical scheme. A copayment or deductible must be indicated in the rules of the medical scheme as approved by the Council for Medical Schemes.” GENERAL EXCEPTIONS The Company shall not be liable for hospitalisation, bodily injury, sickness or disease directly or indirectly caused by related to or in consequence of 18. Co-Payment.

I regret that the above was not positive but trust that you will find the above to be in order and thank you for your patience whilst I was attending to your query. Should you need further clarity on policy functions and benefits, please contact Talksure’s Customer Services department on ***or email them on *** . Yours Sincerely, 
Paul Makwea
Risk and Compliance Department
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