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Medical Gap Cover – Co-Payments & Gap Insurance & Exclusions

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You might believe that you and your family will be sufficiently covered in any event if you have medical aid and medical Gap cover.

The reality of this is, however, more complex.

What Is Medical Gap Cover?

Medical gap cover is a short-term insurance product that works alongside a medical aid scheme. It is designed to provide extra cover and financial protection to those already utilising medical aid, covering the ‘gaps’ between what doctor charges and what the medical aid covers.

In essence, Gap cover can cover the cost of the shortfall between a medical scheme tariff and the rates charged by private healthcare providers. Depending on the type of policy chosen, gap cover can cover the whole or part of the difference between what a medical scheme agrees to pay and the full rates charged by a medical practice.

It must be noted gap cover plans are not stand-alone insurance policies but rather supplemental health plans to reinforce any existing medical cover.

Stepping in to cover routine medical consultations and procedures, gap cover can cover the shortfall on payments for treatments related to several critical illnesses such as cancer, renal problems, strokes, comas and heart attacks.

Does Gap Cover cover Medical Aid Co-Payments?

Firstly let’s break down what a co-payment is to better understand how gap cover and medical aid come into the picture.

What Is a Co-Payment?

A co-payment will vary in each individual case, being a set amount that a medical aid requires their client to pay under specific scenarios. This depends on the procedure or treatment in question as well as the medical aid scheme of the client.

When Does It Apply?

Typically, a co-payment would be required for procedures in hospitals; however, co-payments for common procedures and treatments out of a hospital are becoming more prevalent. It is essential to keep this in mind as the assumption that a certain procedure will be covered could result in outstanding fees building up.

In short, Gap cover is, in turn, a means of covering the shortfall of what is charged by a practitioner and what the medical aid will cover. Therefore, Gap cover does not apply in the instance of medical aid not paying towards a procedure or alternatively covering the full amount for a procedure.

Gap Cover & Co-Payments

Gap cover providers will cover treatments and procedures approved by the respective medical aid involved; however, medical aid co-payments will have to be covered by the client themself. This will differ from provider to provider, case to case, but this is generally the case with gap cover not covering medical aid co-payments.

What To Keep In Mind When Choosing Gap Cover

Gap cover is an excellent addition to any medical aid scheme, allowing you and your loved ones to be covered from every angle in the event of needing medical cover. However, as mentioned, Gap cover is an additional element to be added to the standing medical aid cover.

There are certain limitations to gap cover, which a client should be aware of from the get-go to avoid any misunderstanding or assumptions of cover being applicable.

TRA Gap Cover Options

Total Risk Administrators offers four Gap Cover packages for you to choose a plan that would suit your needs:

  • Basic Cover 300, starting at R99 p/m
  • Vital Cover Plus, starting at R250 p/m
  • Super Cover Plus, starting at R280 p/m
  • Absolute Cover Plus, starting at R495 p/m

Typical Gap Insurance Exclusions

Additionally, your Gap insurance is inextricably linked to your medical aid and only supplements your health insurance policy. Typically, medical aid schemes won’t pay the full rate that specialists and private hospitals charge – which is when Gap insurance will kick in to cover rate shortfalls.

Gap cover serves as additional coverage to what your medical plan will pay from your hospital or risk benefits. Gap insurance benefits usually have the following exclusions – meaning that your Gap insurance will not provide coverage under these circumstances:

  • If your medical aid has not paid a portion of your medical expenses from your hospital or risk benefit.
  • Your Gap insurance cannot be used to pay for upfront fees that must be paid privately.
  • Gap insurance typically doesn’t cover accounts related to depression, emotional matters, or mental illnesses.
  • Events involving drugs or alcohol are usually excluded from a health Gap plan unless it’s part of your PMB.
  • Any transport charges and/or healthcare services a patient receives when transported in an emergency vehicle, vessel, or aircraft are excluded from Gap insurance.

Top Tip: Be sure to review your Gap insurance policy if you or your family have any pre-existing medical conditions. Pre-existing conditions that may lead to hospitalisation will typically have a waiting period before your coverage will be active. Most Gap policy schedules will have different waiting periods for various conditions – and it’s important to familiarise yourself with this information if you or your family might be affected.

Learn More

If you require more information about our medical Gap cover, you can explore our TRA Gap Cover brochure to answer any queries. Alternatively, you can contact one of our specialists to see how Total Risk Administrators can help you and your loved ones today. 

Note: All material on this website is provided for your information only and may not be construed as medical advice or instruction. No action or inaction should be taken based solely on the contents of this information; instead, readers should consult appropriate health professionals on and matter relating to their health and well-being. The information and opinions expressed here are believed to be accurate, based on the best judgement available to the authors, and readers who fail to consult with appropriate health authorities assume the risk of any injuries. Errors and Omissions Excepted. Terms and Conditions Apply.

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