How to compare Gap Cover: A comprehensive guide
How to compare Gap Cover: A comprehensive guide
Gap cover is a vital insurance tool that stands between medical expense shortfalls and the actual costs that come up during hospitalisation or medical procedures. Let’s explore the definition of gap cover, how it works, and why it’s a must-have along with your medical aid.
Definition of Gap Cover
Gap cover is designed to cover the difference between the amount your medical aid pays for a healthcare service and the actual cost charged by healthcare providers. This gap is usually created when a specialist charges more than what your medical aid is willing to pay.
How Gap Cover works
One of the reasons you have medical aid, is because you know how expensive procedures and treatments can be.
Medical aid’s know this as well, which is why your benefits cover different healthcare services. It’s also one of the reasons why there are different types of shortfalls, with these being the most common:
Tariff Shortfalls
Tariff is a term used to describe a wide range of costs associated with medical procedures, tariff shortfalls occur when a procedure or treatment costs more than what your medical aid is willing to pay.
Sub-Limits
Medical aid schemes often put sub-limits on certain procedures like prosthesis or benefits. This means they will only pay up to a certain amount. The shortfall occurs when the procedure costs more than that limit.
Co-payments & Deductibles
As a medical aid member, you will find that there are defined amounts that you need to pay upfront to the hospital. This type of shortfall is common with procedures like MRI scans, scopes and other common procedures like in-hospital dentistry. With Co-payments, Gap Cover refunds the fee you needed to pay upfront.
Instead of paying these types of shortfalls from your own pocket, Gap cover will step in and take care of that unexpected expense. With financial protection like that, all you need to worry about is getting better.
Importance of having Gap Cover
The importance of Gap Cover becomes clear when you realise how expensive these bills can get. For heart and cancer treatments, certain insurers reported gap claims that were between R8 000 – R12 000. For procedures like c-sections, the average shortfall that needed cover was R11 000.
These are serious procedures, where your first concern should be getting the best help available. And even if you were able to pay out-of-pocket, could you not find a better way to spend your hard-earned money?
Gap Cover gives you the power to get the healthcare service you need, without being limited by medical aid or your budget. That level of protection makes Gap Cover one of the most important insurance policies you can have.
Factors to consider when you compare Gap Cover
One of the things that make Gap Cover unique is that it can be added to any registered medical aid plan in South Africa. Becoming a policyholder is easy, but there are factors to consider before choosing your preferred provider.
Understand the limits and exclusions
The benefits you get with Gap Cover plans have limits and exclusions. Most policies will have a limit to how much tariff shortfall cover you get, while some providers will not cover expenses like ward fees, theatre fees, and more.
After you assess what your medical aid covers, it becomes easier to decide which Gap Cover policy has limits you’re comfortable with.
Breakdown the cost
There are two costs to consider when you compare Gap Cover plans: the premium price and the plan price. The price of the premium is first determined by your age. This is done to reflect the risk rate model used by insurance providers.
The price of the plan can also be determined by the level of benefits. Some providers may have benefits that cover medical expense shortfalls for cancer treatment, while some plans have benefits that also include legal and financial advice, counselling and more.
These plans are usually more expensive than standard policies, but those benefits could be exactly what you need. When looking at the cost, always consider the value you will get.
Analyse the waiting periods and claims process
A waiting period is when a policyholder is not entitled to claim any or certain policy benefits under a policy. This is usually the period after taking out a new policy, and it’s done to protect the insurer from people who might want to abuse a policy. When you compare Gap Cover, you will see that many providers have a general waiting period of 3 months and a condition specific waiting period of 12 months. There are also situations where the waiting period can be waived or extended.
There could also be differences in the claims process of the providers you’re considering. Some may ask you to fill out a paper based form, while others may have a simple online process. Majority of providers will need additional documents like Doctor’s accounts or a Claims Transactions History report.
Once you need that shortfall cover, you want to make sure the provider giving it is hassle free.
Actionable tips for choosing the right Gap Cover plan
Once you’ve assessed your favourite plans, becoming a policyholder is as easy as talking to an authorised representative. But before you have that conversation, follow this action plan to make sure you get what you’re looking for:
- Look at your potential medical needs and choose a plan with acceptable coverage limits
- Be aware of waiting periods and choose a plan that aligns with your expected timeline for medical treatments
- Consider exclusions to ensure that the gap cover plan addresses your specific healthcare requirements.
- Compare Gap Cover costs across different providers, considering both premiums and overall value
- Consult with authorised representatives or financial advisors to get guidance based on your unique situation
By following these steps, you will have no doubts about the policy you are getting.
In the end, it’s about peace of mind
Getting Gap Cover could be the difference between doing something drastic to pay hospital bills, or just focusing on your recovery. That’s why it’s important to remember that when you compare medical aid Gap Cover it’s about more than just numbers: It’s about finding the right fit. Assess your needs, compare coverage, weigh the costs and enjoy your protection from medical expense shortfalls.
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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