How do you claim for medical aid Gap Cover? | Dis-Chem Health

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How do you claim for medical aid Gap Cover?

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High medical shortfalls can really hurt your budget, especially if they are unexpected. This is what makes Gap Cover such a great tool, because it can protect you from these shortfalls.  

But even if you had Gap Cover, do you know how to use it? The claims process can be confusing and frustrating when you don’t know how to navigate it, and that’s not the kind of stress anyone wants.  

Don’t worry though, because the Info Hub team will be breaking down some of the most common Gap Cover claims processes. By the end of this article, you will know: 


How to claim for Gap Cover 

In most cases, one of the first things you will need to do is fill out a claims form. Sometimes, you may receive it as part of the policy pack when you join. If not, there should be a downloadable version of the form on the website of your service provider. All you need to do is check the Self-Support portal, which generally has the resources and details on how you can claim. 

Once you submit your claim with all the necessary supporting documents (more on that later), a claims assessor will kickstart the assessment. You or your medical scheme might be asked for more relevant documents during this period, or you may be reminded to send outstanding documents. Once all of that is sorted, your claim will continue to move through the assessment process. 

If your claim is approved, then all that’s left to do is wait until you’re notified that your shortfall has been paid! Waiting periods for confirmation of payment will differ from company to company, so make sure you go through your policy docs to find out how long your waiting period should be.  


When can you claim for a Gap Cover payout? 

Just like the waiting period for confirmation of payment, the waiting period for when you can start applying for Gap Cover claims is different from company to company.  

Most service providers will have a 3-month general waiting period before you can launch a claim. This period could be longer or shorter depending on whether you’ve had Gap Cover before, the condition or procedure where shortfall cover will be needed, etc. Your policy documents explain details like this clearly, so it’s important to go through them.  

Fun fact: Waiting periods exist because they lower the risk for the insurer by protecting them from abuse of the system. If the risk is lower, then the insurer can offer a lower premium. That’s a win for everyone involved, right? 


Understanding the claim process for Gap Cover 

Naturally, the Gap Cover claims process depends on the service provider you use. But generally, most companies have a process that has a few steps. As we’ve already mentioned, the first step is filling in the claims form. Once you’ve submitted, you will be notified that it has been received.  

A claims assessor then starts checking your documents, making sure that everything has been filled out correctly and all the requested documents have been received. Claims volumes may be high so this process can take anywhere between 7 – 14 days. Your service provider will be able to provide you with the details of how long the assessment will take.  

Once the Gap Cover claim has been assessed, you will receive a notification of the outcome. If successful, the payment of your shortfall should be complete in a matter of days. 


The kind of documentation required for a medical aid Gap Cover claim 

If you were to create a checklist of the documents needed for Gap Cover claims, here’s what would be on it: 

  • A completed claims form 
  • Doctor’s accounts 
  • Hospital account 
  • Claims transaction history report 

Other documents may be requested like additional medical reports, but that will depend on your case.  


Common issues that can delay or deny a Gap Cover claim 

As frustrating as it is, there are a few issues that can delay or deny a claim. The main culprit for delaying a claim is missing or incomplete documents. Your service provider may also ask you to do more medical tests on their behalf, at their expense. Claims are normally assessed on a case-by-case basis, so your service provider may ask to review your documents more than once.  

Sometimes, the insured party that claim is being made for isn’t the policyholder. Working with the insured party and the policyholder to get all the necessary documents could prove to be a challenge that delays the process as well.  

Some factors that could result in the denial of a Gap Cover claim include unpaid premiums, as well as the limits and exclusions of your plan. Your claim may be denied, for example, if the medical procedure that was done resulted in a co-payment instead of a tariff shortfall. If your plan does not include a co-payment benefit, your claim can’t be approved.  

Service providers do their best to make sure you understand the scope of your plan, so that denials are kept low. Some companies even give you 3-6 months to appeal a rejected claim, because the goal is to make sure that every case is dealt with fairly.  


How you can ensure your Gap Cover claim is successful 

Due diligence is your best bet when it comes to making sure your Gap Cover claim is successful: 

  • Make sure all the necessary forms have been filled out correctly. Dot every i  and cross every t 
  • Make sure you attach every document needed with your claim. The hospital and your medical scheme will have the resources you need, so make sure you get in touch with them. 
  • Make sure the claims assessor assessing your claim stays in constant contact with you. This way, you’ll be able to quickly sort out any mistakes or missing documents concerning your claim. 

That’s all for this article! The Gap Cover claims process can be difficult to navigate, but we hope this article has shed some light in the tunnel. If you would like to learn more about Gap Cover, check out our most popular articles below. 

Not all Gap Cover plans are the same and benefits as well as limitations may vary. Descriptions of benefits given are meant to be for general educational purposes only and you must ensure that you seek the advice of a broker to ensure any product choice you make suits your individual needs 

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