GAP Cover Explained

June 28, 2020

Justin Els
June 28, 2020

Here’s the truth – even if you think you’ve planned for every emergency by having medical aid, there are still loads of doctors bills that can suddenly surprise you. Usually, while you or your loved ones are trying to recover from a health event. That’s because what doctors and specialists charge is often more than the rate your medical aid will pay for the procedure.

What is Gap Cover?

Gap cover is a short-term insurance product designed to provide extra protection for those who already have medical aid. It covers the deficit between your medical scheme’s tariff (MST) and the actual rates charged by private healthcare professionals.

Medical aid schemes in South Africa currently reimburse doctors and specialists at 100%, 200%, or 300% of the scheme rate. In reality, however, professional medical providers may charge up to five times the base tariff.

Benefits of Gap Cover

By subscribing to gap cover, you protect yourself and your family against this financial disparity, potentially avoiding significant out-of-pocket medical expenses.

Comprehensive Gap Cover options can cover the following:

Up to an additional 500% of your medical scheme rate.
Co-payment Cover
Physical Rehabilitation Top-up Cover
Out-patient Specialist Consultation Cover
Preventative Care
International Travel Insurance
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.
Sub-limit benefit extender – provided to enhance sub-limits imposed by medical aids.

Here are some examples of common medical procedures

Procedure	Actual Cost	Potential shortfall incurred (payable by Gap Cover)
Colonoscopy	R14 509.82	R4 805.42
Back Fusion	R81 499.11	R68 188.31
Tonsillectomy	R19 081.86	R11 958.34
Joint Replacement	R46 660.48	R23 597.41
Hysterectomy	R 12 978	R 8 227
Coronary bypass surgery	R 40 752	R 27 164
Surgical wisdom teeth extraction	R 27 164	R 18 937

*The values in the table are illustrative only; actual costs and medical aid contributions vary across providers

Cover Limits

Policyholders will only be able to claim R165 000 per year, for every insured individual on the policy. In addition, Gap Cover policies have maximum rates. For example, a specialist may charge 700% of the medical scheme rate, but your gap cover may cover you for only 500%, which leaves you liable for the shortfall.

Waiting periods and exclusions

As with conventional medical aid, waiting periods and exclusions apply to gap cover.

Typically there’s a general waiting period of three months for all benefits, as well as a 12-month waiting period for pre-existing conditions. During these waiting periods, you and your family are not eligible for cover.

Exclusions refer to certain procedures and treatments that are not covered by gap cover benefits. These vary according to the provider. Typical exclusions include obesity treatment, cosmetic surgery and specialised dentistry.

Cost

Single members, younger than 60 can get comprehensive cover from as little as R 200pm. Families with members older than 60 can pay up to R 700pm.

Finding The Best Provider

Consult an Independent Financial Adviser for advice on the most appropriate Gap Cover for you and your family. Our Independent Financial Advisers have access to a range of Gap Cover Providers. They are also accredited to advise on your medical aid.

It is important to understand how your Gap Cover Product and Medical Aid will work together to ensure that you can access the care that you and your family need.

There are many other reasons Why you should talk to your financial adviser regularly.