n SA Mercantile Law Journal = SA Tydskrif vir Handelsreg - When is an accident and health policy not an accident and health policy? and : case comments




The legal battle between the Registrar of Medical Schemes ('the Registrar') and Guardrisk Insurance Co Ltd ('Guardrisk') in the cases of 2008 (4) SA 620 (SCA) and 2007 JDR 0868 (W) involved the AdmedGap and AdmedPulse insurance policies. These policies, known in the industry as gap cover, address the problem that arises when the medical aid scheme to which a person belongs does not pay the full cost of medical services. In the event of the insured being admitted to hospital and having to receive medical, surgical or other treatment, or the insured needing chemotherapy, radiotherapy or kidney dialysis as an outpatient, the policies would pay the 'gap' between the cost of the medical services and the amount actually paid by the medical scheme of which the insured was a member. In other words, in exchange for a premium, the policies would pay the difference to the insured.


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