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How Gap Cover for medical expense shortfall works

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Medical Aid is a service that has completely transformed how we access healthcare. If you or a loved one have fallen sick before, then you’ve felt the relief of having medical aid. But sometimes, medical aid isn’t enough… This happens when a specialist doctor charges more than what your medical aid is willing to cover, leaving you to pay the shortfall.

But we’re excited to have you here, because the Info Hub team will be breaking down how you can use Gap Cover for medical expense shortfalls! We’ll be discussing the following:


What is a Medical Expense Shortfall?

As we know, many hospital procedures and treatments are done by specialists. Surgery is done by surgeons, physiotherapy is done by physiotherapists etc. These procedures and treatments are normally extremely expensive, which is why most of them are charged to your medical aid. The procedures and treatments are called Tariffs, which is the term used by medical aids and specialists. Under the broad term of tariffs are different medical codes, which are used to describe a type of procedure or treatment. For example, tariff code 014 relates to General Medical Practice.

This tariff system allows Medical Aid schemes to provide different types of plans, with standard medical aid schemes usually covering 100% – 200% of tariff charges. But sometimes, specialists will charge 300%, 400% or even 500% of tariffs. This is what creates a shortfall, which you need to pay for out-of-pocket. This is where gap cover for medical expense shortfall comes in. A plan covers the shortfall between the medical aid and a specialist, so that you don’t have to use your own money.

In case you were wondering, specialists charge such high tariffs because their practices are expensive to maintain. It’s easy to feel like the overall cost of your procedure is too expensive, but healthcare is not cheap for everyone involved – Including the service providers.


How Can a Shortfall in Medical Expenses Affect Your Finances?

Can you imagine if you took an umbrella thinking that you’re prepared for the rain, only to realise the umbrella has holes? Your medical aid can feel like that umbrella, when it’s not able to cover all your medical expenses. If you were thinking medical aid would cover all of your health expenses, you may decide saving for medical emergencies isn’t necessary. So when you find yourself having to pay out-of-pocket for medical expenses, sacrifices might have to be made. Medical bills tend to pile up, so it can be difficult to plan just how much you will end up spending. Depending on how much those expenses are, you could be forced to dip into your personal savings or even be pulled into debt. The impact a medical expense has on finances may be different for each person, but that impact is almost always negative.


How Gap Cover Can Help with Medical Expense Shortfall

When you’re seeing a specialist, it usually means the treatment or procedure you’re doing is serious. In situations like that, you don’t want finances to stop you from getting the help you need. Having Gap Cover for medical expense shortfall gives you the power to handle the cost of your procedures, even after you find out your medical aid isn’t able to cover the full expense. Depending on the plan you choose, you can be protected from shortfalls for procedures and treatments like childbirths, surgery, implants, cancer treatments and many others. But Gap Cover isn’t just useful for covering medical expenses that you can see coming. When you’re involved in an accident, your medical aid may only be able to cover a portion of your hospital stay. Certain plans provide lump sums for hospital stays in cases of accidents that cause a permanent disability for example. While this level of flexibility is great, it’s important to remember that Gap Cover plans have limits and exclusions that may result in you still having to pay out-of-pocket. But having a cushion for that unexpected medical expense will save you thousands of Rands in the long run.


The Coverage and Benefits Provided by Gap Cover

To qualify for Gap Cover, you must have medical aid. Gap Cover can be seen as an extension of your medical aid, since it protects you from shortfalls that your scheme is unable to cover. Tariff Shortfall cover is usually the standard benefit of many plans, but you usually get much more than that. For example, Gap Cover for Medical expense shortfall can include benefits like sub-limits, standard co-payments and deductibles. With certain procedures like MRI scans, you are usually asked to pay a fee upfront as part of a standard co-payment. If the plan you choose has a standard co-payment and deductibles benefit, you can claim back that upfront fee you paid. Other plans have benefits that focus specifically on shortfall cover for cancer treatments, and you can also access lump sums in the case of accidental death or permanent disability. It all depends on the provider and the different types of plans that are offered. This is why you always need to check the policy documents or speak to a registered broker to understand the full scope of benefits available to you.



That wraps up our quick guide on how Gap Cover for medical expense shortfall works! 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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