What Is Gap Cover In Medical Aid

What is Gap Cover in Medical Aid in South Africa revealed.

We verified gap cover in medical aid in South Africa.

This is a complete guide to gap cover in medical aid in South Africa.

In this in-depth guide you’ll learn:

What is a Medical Aid?
What is Gap Cover?
Is gap cover affordable when you have medical aid?
Why do you need gap cover when you have medical aid?
Why should you consider gap cover?
What are the benefits of gap cover in medical aid?

So if you’re ready to go “all in” with the gap cover in medical aid in South Africa, this guide is for you.

Let’s dive right in…

What Is Gap Cover In Medical Aid Summary

1. Introduction

Medical expenses in South Africa are sky-high.

Few citizens can afford comprehensive medical coverage. Even when covered, they sometimes have to pay an additional amount to hospitals and service providers not covered by their medical aid.

A medical aid’s purpose is to assist you in paying for medical care. Medical aid covers the expenditures of members' healthcare, including hospitalisation, treatments, and medication.

These expenses are covered in accordance with the medical scheme's regulations and the type of medical aid plan that the member subscribes to.

If you require day-to-day benefits, have a chronic ailment that falls under the statutory minimum benefits, or need to be hospitalised, having medical aid guarantees that you will be covered.

One can also get medical insurance. Having medical insurance means you will receive a payout if you are hospitalised and unable to earn a living or work. A daily cash-back or payment per covered event is made to the client at a predefined set amount for each day the client spends in the hospital. There is a maximum amount that may be paid out for each event and a maximum limit amount that can be paid out annually.

Neither of the above addresses the amount charged by the hospital or service provider that is higher than the benefit of your medical aid.

For that, you may make provision through so-called Gap Cover insurance.

2. Definition of Gap Cover Insurance

The short-term insurance product known as Gap Cover is designed to provide additional protection for individuals with medical aid coverage. It compensates for the shortfall between your medical scheme's tariff (MST) and the actual prices that private healthcare providers charge for their services.

3. How Does Gap Cover Work?

For gap insurance to function, it must cover the difference, also known as the shortfall, between the amount your doctor bills for services and the amount your medical aid pays from the Risk or hospital benefit.

You will be covered for medical aid co-payments, cancer treatment shortages, and sub-limits. However, this depends on which option you choose.

A gap cover should not be considered a replacement for medical aid. The purpose of gap cover is to offset deficits that occur when doctors charge more than the rate that is specified by medical aid and when medical aids only pay up to the rate that is set by the risk or hospital benefit.

Gap cover does not provide cover where medical aid does not pay towards a procedure; it only covers the deficit between the rate charged and the Medical scheme tariffs (MST) your medical aid pays.

Most medical aids pay the healthcare providers 100% of the scheme rate. Still, the shortage of medical healthcare professionals allows them to charge rates of up to 500% of the MST.

Medical aid remains the primary way of health coverage. It will cover your stay in the hospital as well as approved medical procedures at a specific rate of cover, according to the option you have selected.

So you can use gap cover to make the expensive co-payments that most medical aid members have to pay at private hospitals, or gap cover plans may pay out a lump sum for the treatment of specified conditions.

Any member of a registered medical aid and their dependents can sign up for gap cover.

Before the coverage begins to take effect, there is a three-month waiting period and one year for conditions present at the time of application.

Most policies do not cover cosmetic surgery, specialised dental care, or obesity treatment.

Your gap cover provider may also refuse to pay if you do not submit a claim within the first six months after receiving treatment. Coverage is provided up to a specific limit, above which you are not eligible to make a claim.

Gap Cover providers offer a wide selection of products with varying restrictions to accommodate customers of varying financial means.

4. What Is Covered by Gap Cover and What Not?

The purpose of gap cover is to offset deficits that occur when doctors charge more than the rate that is specified by medical aids and when medical aid only pays up to the rate that is defined by the risk or hospital benefit.

If medical aid pays nothing toward a procedure or covers the entire cost of a procedure in full, gap cover will not provide more coverage for the patient.

With a few notable exceptions, Gap cover does not pay for the following:

➡️ The excess costs of consultations before or after in-hospital treatment

➡️ Medication, as well as single-use goods both within and outside of the hospital

➡️ Crutches and wheelchairs

Further, suppose your medical aid does not contribute anything toward the cost of pathology (blood tests); your gap cover will probably not contribute anything toward the price of pathology either. Your Gap Cover may pay for the remaining balance if your Medical Aid only pays for half of the amount.

Note that gap cover is intended to cover treatment and procedures received in hospitals and specific treatments and procedures received by outpatients who meet specified criteria, such as chemotherapy and radiation for cancer treatment, particular scopes and scans.

5. When Does Gap Cover Pay Out?

It may take between four and six weeks for gap insurance returns. However, you can speed up the process by communicating with your gap insurance provider and promptly returning any documents that must be signed.

It is recommended that your Gap Cover claim be submitted as soon as possible after your medical scheme has paid its half of an account; nevertheless, the claim must be submitted within four months of receiving payment from the medical scheme.

Claims for Gap Cover are processed per the provided medical aid statement. Then they are cross-checked with the necessary doctor's and hospital accounts to determine any applicable shortfalls, co-payments, or sub-limits.

This is compared to the terms of your policy, and an evaluation is performed based on the benefits, limitations, and waiting periods that apply to each benefit.

It is essential that, before filing a claim, you study the documentation about your insurance policy and become acquainted with your benefits, waiting periods, and any applicable exclusions.

6. How Can You Get Medical Aid Gap Cover?

Several brokers in South Africa provide members of medical aids with education and information regarding the most effective gap cover solutions.

These brokerages can create a gap cover solution specifically suited to every person’s needs.

Alternatively, you can get prices and plan information from all South African providers if you want to compare gap cover policies.

After that, you'll need to evaluate the various possibilities, but comparing gap cover quotes can be difficult, confusing, and time-consuming.

Gap cover brokers can help you quickly identify and compare gap cover quotations and be there for you at every stage of the application process.

They will inquire about your existing medical coverage, as well as your lifestyle, requirements, and financial constraints, and then provide recommendations regarding a gap cover solution that is suitable for you.

Companies that offer gap cover plans in South Africa include Zestlife, Stratum, Turnberry, Essential gap cover, Old Mutual, Elixi, ABSA, Sanlam, Discovery, and more.

Factors to consider when choosing a provider include the following:

➡️ The amount of cover needed for you and your family.

➡️ The monthly premium and whether it is affordable for you

➡️ Terms and conditions of the gap cover

➡️ The provider’s reputation and track record

7. Is Medical Aid Gap Cover Worth It?

In reality, most South Africans can't pay the difference between what they are charged and what their health insurance will cover.

Gap cover is a must-have if you have a registered South African medical aid since it will protect you from shortfalls and co-payments.

8. Frequently Asked Questions

Does Gap Cover Pay for Medication?

No, gap cover does not pay for medication and disposable items in and out of hospital.

Does Gap Cover Pay for MRI scans?

Gap Cover may pay for MRI scans if you choose an option that covers co-payments on approved endoscopies, MRI and CT scans and cancer-related claims.

Does Gap Cover Have a Waiting Period?

Yes, gap cover has a three-month general waiting period and a waiting period of one year for conditions that were present at the time of application.

Does Gap Cover Only Cover In-Hospital?

No, gap cover covers in-hospital treatment and procedures and certain defined out-patient treatment and procedures such as chemotherapy, radiation, and certain scopes and scans.

Is Gap Cover the Same as Medical Insurance?

No, gap cover provides additional protection for individuals with medical aid coverage.