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What is Gap Cover?

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What is Gap Cover?

Gap Cover is a non-life insurance policy that covers medical expense shortfalls for hospital procedures and certain outpatient treatments. Gap Cover complements your medical aid. You must be a member of a registered medical aid to have Gap Cover.

Gap Cover will only cover what your medical aid plan covers, so if you had a medical procedure that’s excluded by your medical aid, you won’t be able to claim it from your Gap Cover.

Medical aids may pay up to 100%, 200% or even 300% of their tariff for hospital treatments and procedures, depending on your chosen plan. Many healthcare providers charge much higher, some up to an additional 500% of medical aid rates, meaning more people are at risk of having to pay a shortfall which can amount to a lot of money. If you do not have Gap Cover to cushion the blow, the unexpected financial expense can mean having to access savings, getting into debt or leaving your family in dire financial need.

So having medical aid doesn’t mean you’re 100% covered for hospital procedures.

According to the latest report by the Council for Medical Schemes, medical scheme members paid more than R32 billion in out-of-pocket payments last year.

That’s why Gap Cover is a necessity.


How does Gap Cover work?

To be covered, your medical aid must first pay their portion of the claim, so that you may claim the shortfall (difference). For an example,

Mr S is on a Medical Scheme – plan A which covers him to a maximum of 100% of the Medical Scheme rate. This means that the Medical Scheme will pay all expenses towards Mr S’ Treatment costs. The Medical Scheme rate for a total colonoscopy is R2 000 (100%) which means that the maximum that the Medical Scheme will pay is R2 000 (100%).

The specialist performing the procedure charged R12 000 which is six times the Medical Scheme Tariff (600%). The maximum Benefit payable by this Policy for this procedure is therefore:

  • R12 000 – Fee charged by the specialist
  • LESS R2 000 – Benefit paid by Medical Scheme
  • = R10 000 – The gap cover Benefit.

Claims are assessed on a line-by-line basis. Each line has a code on your healthcare or service provider’s account, and this accounts for the total amount charged. These codes describe the medical procedure/s or treatment/s that was performed or the service that was provided. Your medical scheme must pay a portion of the cost of a coded line from your hospital or risk benefit in order for that claim line shortfall to be covered by your Gap Cover. Unless you are claiming for a Benefit with different qualifying criteria such as a Family Protector or a defined co-payment.

Healthcare is expensive but health is priceless.


What does Gap Cover in South Africa typically cover?

In general, Gap Cover in South Africa covers the following:

  • Tariff shortfalls/ Medical expense shortfalls – In situations where your medical aid does not cover all your medical expenses, Gap Cover can pay up to an additional 600% to cover the shortfalls.

Depending on the insurance provider and the medical aid plan type, Gap policies can include additional benefits such as:

  • co-payments, deductibles and shortfalls from sub-limits.
  • Cover for dental reconstruction, cancer treatment, hospital boosters (lump sum payments for lengthy stays in hospital), and premium waivers.
  • Cover for premature birth, child casualty illness and accidental emergency department visits.
  • These benefits help ensure your whole family is well taken care of and receiving quality healthcare without worrying about medical expense shortfalls.

    Gap Cover does not only take care of your physical well-being but goes a step further and takes care of your emotional and mental well-being with additional non-medical benefits like counselling.

    It is important to note that Gap Cover policies may have exclusions or limitations. For example, some may not cover cosmetic surgery, infertility and experimental treatments.



    Who is Gap Cover for?

    Gap Cover is a great top-up to your medical aid plan, giving you access to the best healthcare treatment without having to worry about the cost. Inflation rates in South Africa are ever-increasing and so is the cost of quality medical care. There are a range of Gap Cover plans to suit every pocket. Gap Cover premiums start from under R150 per person per month.


    How to choose the best Gap Cover

    When looking for Gap Cover, there are many factors to consider.

    Does the Gap Cover you’re interested in cover sub-limits, co-payments and deductibles?  Many medical aid members are restricted to using certain network providers, with penalties and co-payments applied if patients go outside of these networks. In cases of an emergency, you might not get the chance to choose a network hospital or network provider.

    If you’re on a comprehensive medical aid plan, you may only need a basic Gap Cover plan. We suggest you contact your broker who will be able to guide you through the Gap Cover plans available in South Africa to help you find the most suitable Gap Cover for you and your family.

    Here are other factors to consider:

    1. The cost of the policy
    2. The benefits and limitations of the policy
    3. The reputation and reliability of the insurance provider
    4. The financial stability of the insurance provider
    5. The policy’s waiting periods

    Gap Cover provides additional financial protection for families who have medical aid. It covers unexpected medical expenses that are not fully covered by medical aid plans, providing peace of mind and financial stability. By conducting thorough research, seeking advice from trusted sources, and selecting the best Gap Cover policy, you can ensure that you are adequately protected against unexpected medical expense shortfalls.


    Frequently asked questions

    Is Gap Cover the same as traditional health insurance?

    No, Gap Cover is a supplement to your medical aid, specifically designed to cover shortfalls in medical expenses that may not be fully covered by your existing health plan.

    Can Gap Cover be purchased as a standalone insurance policy?

    No, Gap Cover is not a standalone policy. To be eligible, you must first be a member of a registered medical aid scheme in South Africa.

    Does Gap Cover include coverage for pre-existing medical conditions?

    Yes, but pre-existing conditions are excluded for 12 months (12-month condition specific waiting period). Gap cover is also there for planned medical or surgical procedures provided the waiting period has been served.

    Can Gap Cover be used for elective or cosmetic surgeries?

    Cosmetic surgery is excluded. However, elective surgery may not be excluded. For example: A wisdom tooth extraction is elective if not an emergency by definition of the scheme, which is why that procedure is covered. It’s essential to review the policy details to understand the exclusions.

    Does Gap Cover provide mental health cover?

    Gap Cover may offer non-medical benefits like counselling for emotional well-being. However, coverage specifics can vary, and reviewing the policy details is advisable.

    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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