Gap cover is a short-term insurance product designed to provide extra protection for those who already have medical aid. It is designed to pay the ‘gap’ or shortfall between what your medical scheme pays, and what a private doctor charge.
Every year, your medical aid sets a medical aid rate, which is the base rate that can be charged by every medical professional for every procedure. Most medical aids pay between 100 and 300% of this rate. However, many specialists or hospitals charge more than 300% of the medical aid rate. For example, if a surgeon charges 500% of medical aid rates, your medical aid will cover the first 200% and you will have to pay the additional 300%.
This shortfall is usually manageable for non-urgent treatment because you can plan around the costs of the procedure. However, a sudden illness or an accident can mean that there’s no time to plan or save, and the shortfall – even on a good medical aid – can run into tens or even hundreds of thousands of Rands.
With suitable gap cover, you’ll also qualify for lump sum benefits to cover costs related to the medical treatment of certain cancers, internal prostheses, accidental dentistry and treatment and care in a casualty ward.
To claim from gap cover, you’ll need the hospital bill, plus your medical aid’s statement of the shortfall with explanatory codes. The gap cover payout will be paid to you, and you will need to make payment to the hospital or medical practitioner. It is important to understand that gap cover will never cover something that your medical aid excludes (cosmetic surgery, for instance). It only tops up a shortfall on approved procedures, specialists or medications.
Who can benefit from Gap cover?
Anyone who’s a member of a registered South African medical aid scheme. Benefits extend to your spouse and dependent children up to a certain age, provided all members of your family belong to your medical scheme and the same medical aid plan or option.
As with conventional medical aid, waiting periods and exclusions apply to gap cover. Typically, there is a general waiting period of three months for all benefits, as well as a 12-month waiting period for pre-existing conditions.
Not all gap covers offer the same terms and cover, it is thus very important that you speak to a broker that is familiar with the product and that can offer the best advice.
If you have any questions or would like to apply for gap cover, you are welcome to contact us.
Author: André Willemse (Financial Advisor & Short term Broker – Vision Insurance Brokers)