What is Gap Cover?

Medical Top-Up Insurance, more commonly known as GAP COVER, is a low-cost-high-value insurance product that you take out in the event that your medical aid doesn’t cover all costs for a hospital procedure or emergency surgery.

 

Concerned brokers and even medical aid providers recommend this insurance. Having Gap Cover is of critical importance, especially when you get that dreadful shock when you see the doctor’s bills after leaving hospital, and your medical aid won’t cover the whole amount!  

 
There are even some specialists in South Africa who will refuse to perform surgery on someone who doesn’t have gap cover, as they have experienced partial payments from medical aid schemes in the past and want to avoid that happening again. There are people who require procedures but are unable to do so because they can’t afford it.

 

With the current state of government hospitals, would this really be an option for them? With Gap cover, it means that a medical aid member will also be able to get the best surgeons/specialists without worrying unnecessarily about costs.

 
Over the years, the gap between what medical aid schemes fund, and the cost of hospital procedures, has just grown too large to ignore. From a single hospital admission, the account could run into hundreds of thousands of Rands and, without available cash or a product such as Gap Cover, could lead a family into a financial crisis.

 
Whether you are young and healthy or aging and not so healthy, you need Gap cover! We live in a country where the crime rate is high, and road accidents occur every day, putting good people in hospital unexpectedly.

 

If you are a medical aid member with one of the recognized schemes in South Africa and are able to get medical aid gap cover for you and your family, you really shouldn’t even have to think about whether to do so or not. It’s a good idea to plan ahead…….and Gap cover will be your solution to avoiding a possible financially-crippling medical event!

 
Depending on your medical aid option, the shortfalls you may experience whilst confined to hospital for a procedure/surgery are as follows:

TARIFF GAPS

This is the difference between what your medical scheme is prepared to pay (EG. 100%, 200% or 300% of scheme tariff) and the actual surgeons and specialist charges. Selected GAP products will cover the difference, up to maximum 500% of the scheme tariff.

CO-PAYMENTS/DEDUCTIBLES    

This is a portion of the cost of an admission/procedure/investigative procedure as listed by the scheme which the member is required to pay (EG. MRI/CT scans, back surgery, hospital admission fee, etc). Selected GAP products provide cover for these listed amounts.

SUB-LIMITS 

These are limitations imposed by the medical scheme on its members (as listed) for in-hospital procedures (EG. Internal Prosthesis). Selected GAP products provide an amount to assist with sub-limit shortfalls.

CANCER TREATMENT

Most schemes today will fund a limited amount towards Chemotherapy, Radiation and Cancer Biological drugs. GAP provides an additional amount to assist with shortfalls on these treatments.

GAP insurance will NOT provide cover for the following:

• External Prosthetics
• Hospital accommodation
• Exclusions and procedures excluded by medical aid scheme
• Day-to-day consultations (out of hospital) with doctors/specialists/dentists/optometrists, etc
• Drugs/medication/bandages/disposables/spectacles, etc
• Pathology (blood tests) and general diagnostic radiology (x-rays) out of hospital
• Penalties levied to members by medical scheme for use of non-network hospitals, non-authorization, etc.

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