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When gap insurance doesn’t cover you

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Gap cover covers the gap or shortfall between what your medical aid scheme pays and what private doctors charge for in-hospital events. People assume that if they have a medical aid scheme that they cover 100% if an operation arises. This is not always the case! Gap cover is not very expensive and is so worth having in conjunction with your medical aid. Iit helps to give you extra peace of mind.

What will most gap cover policies cover or not cover?

It’s important to remember that Gap cover is the shortfall between private doctors and in-hospital medical aid payments, and checking your fine print won’t hurt. Here is a list of things most gap policies won’t pay for:

Ward costs in a hospital facility;

Upgrades to a private room;

Pre-admission consultation costs;

Medication (both in-hospital and take-home);

External prostheses (an artificial breast or a prosthetic leg);

Wheelchairs or crutches;

Routine medical examinations, such as ultrasounds;

Home or private nursing;

Extra costs related to weight/BMI-related procedures;

Mental health disorders, transportation costs (such as in an ambulance);

Out-of-hospital dental treatments;

Cosmetic procedures;

Costs incurred for treatment by a non-designated service provider (determined by your medical scheme); and

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

On the plus side, your gap cover policy (depending on your provider) may cover things like:

> Some out-of-hospital procedures that used to be require hospitalisation,

> Co-payments for certain specified hospital procedures (in full). Speak to your insurer for details.

> A contribution to cancer treatment costs once your cancer benefit on your medical scheme has run out.

> The shortfall on internal prostheses (such as a hip replacement procedure) up to a stipulated maximum.

> A lump sum for first-time cancer diagnosis (terms and conditions usually apply).

> Lump sum benefit for accidental death or permanent total disability.

> Tooth repairs in the case of accidental injury (such as breaking a tooth in a car accident).

> Some casualty costs (terms and conditions apply).

When looking into various gap covers, you can do comparisons online or if you have already narrowed down the gap covers that are of interest to you – then do yourself a favour and speak to an advisor who will be able to answer all your gap related queries.

Medical Gap Cover Questions & Queries

If you do have a medical aid plan or get one, it is important to also consider Gap Cover as an additional health insurance product.

If you have any more queries or questions regarding anything related to TRA Gap Cover, why not reach out to our helpful specialists here. You can also visit our Gap Cover here.


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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