Gap cover is not just a nice to have. It should be an essential gap cover insurance product that should be a part of your medical aid plan.
Gap cover companies aim to help you in instances where there is a shortfall between what a service provider will charge and what your medical aid scheme will cover for in-hospital expenses, as not all medical expenses will be covered by your medical aid scheme.
What are my Gap Cover Provider/Company Options?
There are many gap cover options to choose from, and it really comes down to what you need and what suits your budget. It’s crucial to select a provider that aligns with your medical scheme membership requirements.
A good idea is to check in with your medical aid scheme to find out what gap cover plans work well with them. Different providers offer varying levels of coverage, from basic in-hospital protection to comprehensive additional benefits.
It is in your best interest to chat to an advisor who works with a number of medical aid and gap cover companies to get the best gap cover plan to suit your needs. Keep in mind that you cannot get a gap cover policy without having a medical aid plan in place first.
How Do Gap Cover Plans Differ?
Most gap cover plans work roughly the same way, but there are important differences to consider:
Coverage Options
Different gap cover options provide varying levels of protection. Some medical scheme rates leave larger tariff shortfalls, which different gap cover insurance products address differently.
Plan Tiers
Most companies offer different product plans or tiers with features such as:
- Coverage for hospital treatments and hospital admissions
- Co payments and penalty co payments handling
- Sub limits on specific treatments
- Pre existing conditions clauses
- Overall annual limit structures
- Annual limit per insured person
Specialised Coverage
Many gap cover plans now include coverage for:
- Oncology treatment and approved cancer related claims
- Cancer treatment protocols
- Dental reconstruction and accidental dentistry
- Trauma counselling and mental health support
- Accidental casualty and accidental death benefits
- Defined procedures with maximum amount guarantees
Pricing is another factor that people consider, so don’t just pick the cheapest option without doing your research first. Remember that you are in control of your options, and if you have done enough research and had a medical aid advisor weigh in, you have the choice on what gap cover plan will work for you.
How Does Gap Cover Work?
Gap cover cover benefits work by paying the difference between what your medical scheme covers and what healthcare providers actually charge. Let’s look at some common hospital procedures to understand how gap cover pay works:
| Procedure | Actual Cost | Medical Aid Pays | Gap Cover Pays | Your Cost |
| Hysterectomy | R12,978 | R4,751 | R8,227 | R0 |
| Coronary Bypass Surgery | R40,752 | R13,588 | R27,164 | R0 |
| Surgical Wisdom Teeth Extraction | R8,227 | R4,302 | R3,925 | R0 |
| CT Scans (series) | R6,500 | R2,000 | R4,500 | R0 |
| Private Ward Upgrade | R5,000/day | R2,000/day | R3,000/day | R0 |
The values in the table are illustrative only. Actual costs and medical aid contributions vary across providers and medical scheme options. Ref: https://www.medicalaid-quotes.co.za/articles/gap-cover
By having a gap cover policy in place, you close the gap between medical aid covers and actual medical bills, giving you affordable protection and ensuring you can afford the care you and your family need without facing unexpected medical expense shortfalls.
What Does Gap Cover NOT Cover?
It’s important to understand the limitations of your gap cover plan:
- Cosmetic surgery (except breast cancer-related reconstruction)
- Most Out-of-Hospital treatments and procedures
- Voluntary use of own service providers when network providers should be used
- Services exceeding overall annual limit thresholds
- Pre existing conditions during initial waiting periods
- Some sub limits on specific treatments like internal prosthesis
Gap Cover Benefits: Why You Need It
Gap cover provides peace of mind by protecting you against unexpected medical expense shortfalls and ensuring you can afford quality healthcare. For a comprehensive breakdown of all gap cover benefits, read here.
Gap Cover Questions & Queries
If you have any more queries or questions regarding Gap Cover, reach out to our helpful specialists. Our team can explain gap cover benefits, waiting periods, pre-existing conditions clauses, co-payments handling, and help you select the best gap cover plan for your situation.
You can also visit our full Gap Cover page for more resources and detailed information about different medical aid and gap cover companies options.
References:
https://www.gapcover.co.za/frequently-asked-questions/
