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All you need to know about gap cover

Jul 1, 2022

Suppose that you have a medical aid policy, and while it might cover some medical possibilities, it also might not pay for all medical expenses. Gap cover would be the perfect contingency plan to cover these costs.

An additional layer of protection for people with medical aid, gap cover is a short-term insurance product designed to foot the rest of your medical bill, when your medical aid falls short. In other words, it compensates for the difference between your medical scheme’s tariff (MST) and the actual rates charged by private healthcare professionals.

Doctors and specialists are currently reimbursed 100%, 200%, or 300% of the scheme rate by medical aid schemes in South Africa. However, it is possible for professional medical providers to charge up to five times a base tariff.

Typical high quality gap cover products cover in-hospital and specified out-patient services for up to 500% of the MST. Furthermore, certain surgical procedures, diagnostic scans, and hospital admissions are covered. With gap cover, you can protect yourself and your family from financial disparities, potentially avoiding significant out-of-pocket expenses.

As a first step, it is important to point out that gap cover includes primarily in-hospital treatment and procedures as well as some defined out-patient treatments and procedures, such as radiation and chemotherapy for cancer treatment, particular scopes, and scans. In the event that your medical savings account is depleted, your gap cover policy will not provide coverage for any day-to-day shortfalls or charges.

For outpatient treatment, the balance of what is not covered by medical aid can be claimed from gap insurance if the treatment was administered in the hospital’s emergency or trauma sector if that is a benefit.

A medical emergency, on the other hand, is characterized by the sudden, unexpected onset of a medical condition that requires immediate medical attention. Typically, medical aid hospital coverage will cover this if the patient is admitted. The actual charges for specialists can, however, be much higher than the medical scheme’s benefits, so gap cover can be used to make up the difference.

Another aspect of gap cover that is important to unpack is hospital choice. Medical aid plans typically specify which hospitals should be used in order to reduce costs. Using non-network hospitals may result in the medical aid rejecting any fees above its tariff and imposing a co-payment. This may or may not be covered by your gap insurance policy, depending on whether it provides partial coverage or not.

As with any type of insurance, the terms and conditions of gap cover vary depending on the insurer. The most important term to always look out for is the gap cover limit, which is the maximum amount that the gap cover will pay. For most insurers, the limit is 600% of the medical scheme tariff, less the amount paid by the medical aid.

Exclusions, that is specific treatments and procedures that are not covered by gap cover, also vary with service provider. These often include procedures such as cosmetic surgery, obesity treatment, and specialised dentistry. In terms of waiting periods, the general rule is that a three months waiting period is instituted for all benefits, while pre-existing conditions normally carry a 12-month waiting period.

For everyone who has a medical aid, gap cover ought to be an essential component of their plan for alleviating medical risk. Finding out that you might end up with devastating medical expenses whenever you or any of your family members require medical attention, even if you have medical aid, might be a hard pill to swallow. However, it’s a reality that you might need to face. In these instances, gap cover can come to the rescue to cover these unforeseen expenses. Let us help you choose the best cover to bridge the gap in your medical expenses today, contact us now.