Even if you have excellent medical aid, you are likely to find yourself having to fill the gap between what a hospital or medical practitioner charges, and the amount your medical scheme is prepared to pay. Total Risk Administrators offers gap cover policies to help you fill these shortfalls. In this guide, you will learn all you need to know about gap cover.

What is medical gap cover?

A gap cover policy is a short-term insurance product, designed to provide extra cover and financial protection to those already utilising medical aid. Gap cover can cover the cost of the shortfall between your medical scheme tariff and the rates charged by private healthcare providers.

Depending on which policy type you choose, gap cover may cover all or part of the difference between the amount your medical scheme agrees to pay, and the full rates charged by the medical facility. Accordingly, gap cover plans are not stand-alone insurance policies, but are group supplemental health plans intended to augment your existing cover.

In addition to covering routine medical consultations and procedures, gap cover can make up the shortfall on payments for treatments related to several critical illnesses, including cancer, renal problems, strokes, comas and heart attacks.

Types of medical gap cover

Total Risk Administrators offers four different types of medical gap cover. They are as follows:

Basic Cover 300

The basic plan provides gap cover for casualty visits and provides up to R3000 in cover when the insured suffers from accidental death. It also covers oncology diagnostics and treatments. It also includes the TRA Assist facility, which provides a Home Drive service (including access to free Uber trips), a Panic Button and a Medical Health and Trauma counselling Line.. This policy starts at R99 per month.

Vital Cover Plus

In addition to the cover provided on the Basic Cover plan, this product also includes Sub-Limit cover on internal prostheses, as well as offering up to R10 000 per policy per annum on co-payments. This plan costs R220 per month for under 65’s.

Super Cover Plus

For an additional R30 per month, the Super Cover Plus policy includes the benefits of the Vital Cover Plus plan, as well as a Global Fee Benefit. Where a global fee has been negotiated between a medical aid and service providers for a specific procedure, and the service providers then charge in excess of that amount, the policy will cover the additional amount.

Absolute Cover Plus

Our flagship gap cover product offers full gap cover, casualty cover, co-payment cover, sub-limit cover, and an augmented oncology cover that includes gap cover, co-payment cover and an Extender plan. This policy costs R450 per month for under 65’s.

The benefits of medical gap insurance cover

It is not unusual for medical expenses to exceed medical scheme benefits, leaving people having to use savings or credit facilities to cover costs. Medical gap policies are there to help reduce exposure to these debts, and to enable you to cover your expenses without having to borrow or use cash you had set aside for other purposes.

Gap insurance cover pays some, or possibly all the gap between your medical scheme’s payment and the fee demanded by medical practitioners. Total Risk Administrator’s gap cover consists of several separate benefits that can be applied to different types of medical expenses.

> Basic Gap Cover helps you avoid out-of-pocket expenses for various medical treatments.

> Casualty Cover makes sure that you are prepared for unexpected visits to hospital casualty wards.

> Oncology Gap Cover is designed for diagnostics and treatment in cancer cases.

> Co-payment Cover gives you peace of mind when it comes to co-payments and deductibles.

> Sub-Limit Cover is there to assist when medical schemes impose sub-limits on in-hospital prostheses or limit the monetary amount that is available for MRI and CT and PET scans.

> Global Fee Benefit comes into effect when medical facilities charge more than the agreed global fee on a specific procedure.

> Oncology Extender Benefit includes any approved costs above an annual scheme oncology limit, subject to the scheme covering costs up to that limit.

Medical Gap insurance plan requirements

To qualify for medical gap cover, you must be an existing member of a medical aid scheme. If you have an existing medical condition, you can still qualify to take out the gap cover policy. However, no claims relating to certain pre-existing conditions will be covered within the first ten months of membership. This includes cover for pregnancy.. If you have any of the pre-existing conditions, you are still welcome to join the scheme, but you will not be able to claim in relation to those conditions until the waiting period is over. After this waiting period, claims in relation to these conditions will be considered. There is no entry age limit, although premiums are higher for clients who are 65 and older.

Total Risk Administrators will provide gap cover for you, regardless of what medical scheme you are already on (as long as it is registered with the CMS). The gap cover will provide benefits for members and their dependants (spouse and/ or child/children up to the age of 25 years only ) who are covered on one policy of a registered medical aid scheme. Members and their dependants can only be on two different medical aids and one Gap Cover Policy if they are legally married, or common law partners verified by submission of an affidavit confirming 12 months of cohabitation.

The provision of gap cover is subject to an aggregate annual limit of R165 000 per insured person per annum.

What most medical gap policies do and do not cover

It’s important to remember the limits of gap cover. There are several things that Total Risk Administrators’ policies will not cover. These include but are not limited to:

> Ward costs in a hospital

> Upgrades to a private room

> Pre-admission consultation costs

> Medication

> External prostheses

> Wheelchairs or crutches

> Routine medical examinations

> Home or private nursing

> Extra costs related to weight or BMI-related procedures

> Mental health disorders

> transportation costs

> Out-of-hospital dental treatments

> Cosmetic procedures

> Costs incurred for treatment by a non-designated service provider

> Co-payments for any procedure for which you are in a waiting period

It is also important to note that gap cover schemes will only pay the shortfall on claims for which your medical aid has already partially paid. Where your medical aid does not cover any portion of the account, you cannot claim from your gap cover. For procedures such as paid MRI, CT and PET scans, medical aids sometimes reject claims, and gap cover cannot help in these instances.

If you have to visit an emergency room for any reason and have a medical aid scheme with a Medical Savings Account, you can generally claim the costs from your savings. Medical gap plans will usually only cover these types of claims for accidents only, or for children under the age of eight, subject to certain other conditions.

Medical gap insurance waiting periods

Most medical gap policies apply waiting periods for various pre-existing conditions. During these waiting periods, the insured individuals are not able to claim from the plan. With Total Risk Administrators, there is no general three-month waiting period. However, there is a ten-month waiting period for a variety of conditions, including the following:

> Head, neck and spinal procedures

> Endoscopic procedures

> Pregnancy and childbirth

> Gynaecological conditions

> Joint replacement

> Inability to walk or move without pain

> Any renal or bladder conditions

> Cardiac conditions

> Dentistry

> Cataracts or eye laser surgery

> Neurological conditions and procedures

> Organ transplants

> Reconstructive surgery as a result of an incident or condition that occurred before membership

> Mental health or psychiatric conditions

> Varicose veins

> Oesophagitis, gastroenteritis

> Male genital system problems

> Carpal tunnel syndrome

> Ear, nose and throat procedures

> Diabetes

If a Policyholder is diagnosed with any form of cancer prior to membership, all related claims will be subject to a nine (9) month waiting period. If a Policyholder has previously been diagnosed with cancer and is currently in remission, the Policyholder needs to advise the insurer by way of medical evidence that the remission period has been for two (2) or more consecutive years.

NO claims relating to any pre-existing condition/s that may lead to hospitalisation (excluding cancer: see above) will be covered within the first six (6) months of membership. The insurer reserves the right to request any clinical information from a Policyholder’s doctor should a claim in this period indicate, and/or relate to, a pre-existing condition. All claims for these conditions received within the waiting period will be reviewed by medical management to identify pre-existing conditions.

How to choose the best medical gap policy

Before signing up to a medical gap cover plan, the best thing to do is to pursue the policy very closely. Firstly, check what is covered and not covered in the policy. Will it meet all your needs? Are there exclusions that will not suit you?

Then, check if there are any conditions relating to the age of the insured. Some policies will stipulate different premiums for different age groups. Make sure that the premiums are affordable and reasonable for your specific age group.

Next, see what the policy’s waiting periods are. Some gap cover plans impose a general three-month waiting period for all new members (Total Risk Administrators does not). There are waiting periods relating to specific conditions, as discussed above. If you or any members of your family have any of the stated conditions, you will not be able to claim until the stipulated waiting periods have passed.

Having read through all of the terms and conditions, look for reviews of the gap cover provider on Hello Peter and similar review platforms. If the reviews are mostly good, you can maybe trust the scheme. Don’t just look at star ratings though; read the reviews thoroughly and see what people have to say about the insurer. How is their service? Have there been problems with claims, etc.? The first few reviews on a site, together with the aggregate star rating, will give you a good idea of what to expect from the provider. However, negative reviews aren’t everything- and if there have been negative reviews, ensure to check whether the review was responded to timeously and efficiently, which is also a good sign.

Lastly, weigh up the premiums against the expected benefits, and make a judgement call on whether it seems a worthy exchange.

Common questions about medical gap policies

Is a medical gap policy tax deductible? Unlike the contributions you make to your medical aid scheme, gap cover cannot be claimed as a tax credit. You can, however, include your gap cover contributions under ‘not paid by medical aid’ on your tax return.

What are the maximum benefits?Total Risk Administrators provides a maximum aggregate benefit of R165 000 per insured person per annum.

What does GAP stand for? ‘Gap’ is not an acronym in this instance. It refers to the actual gap or shortfall between the rates charged by medical facilities and the amount a medical scheme is prepared to pay.

How long is medical gap insurance valid for? There is no time limit on the validity of gap cover. As long as you are paying your premiums, your policy is active and valid. There is also no maximum expiry age.

Is it worth purchasing supplemental health insurance? Considering the fact that medical aid schemes consistently fall short of the total fees demanded by medical service providers, it is most definitely worth having gap cover. For a small monthly premium, you can increase your and your family’s cover for medical expenses. This is much better than having to find money to deal with unexpected costs.

Will the medical gap cover pay for my consultation with the doctor? No, gap cover will not pay for routine GP consultations or pre-or post-operative check-ups.

Can I get one month’s gap medical cover? No. You need to take gap cover on an ongoing basis over an extended period.

Does a medical gap policy pay a lump sum? No. Medical gap cover will only pay specific amounts in respect of medical scheme payment shortfalls on specific medical services. However, some of the additional benefits on the policy may offer lump sum pay-outs.

How do I get gap health insurance? Contact Total Risk Administrators or fill in our online application form.

Total Risk Administrators is a provider of funeral cover, female cancer cover and medical gap insurance. Contact us for more information. www.totalrisksa.co.za

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 any matter relating to their health and well-being. The information and opinions expressed here are believed to be accurate, based on the best judgment 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.