Gap cover is a short-term insurance product designed to provide extra protection for those who already have medical aid. It covers the deficit between your medical scheme’s tariff (MST) and the actual rates charged by private healthcare professionals.
Medical aid schemes in South Africa currently reimburse doctors and specialists at 100%, 200%, or 300% of the scheme rate. In reality, however, professional medical providers may charge up to five times the base tariff.
By subscribing to gap cover, you protect yourself and your family against this financial disparity, potentially avoiding significant out-of-pocket medical expenses.
Top-tier gap cover benefits
Top-tier gap cover products offer in-hospital and specified out-patient benefits, up to 500% of the MST. In addition, they may cover co-payments related to hospital admissions, certain surgical procedures and medical scans.
Many South African medical aid schemes require members to make co-payments if they use hospitals other than those in the scheme networks. With gap cover, this mandatory co-payment is covered up to a certain amount per family per year.
With suitable gap cover, you’ll also qualify for lump sum benefits to cover costs related to the medical treatment of certain cancers, internal prostheses, accidental dentistry and treatment and care in a casualty ward.
Who is eligible for gap cover?
Anyone who’s a member of a registered South African medical aid scheme and who is 60 years of age or younger qualifies for gap cover.
Benefits extend to your spouse and dependent children up to a certain age, provided all members of your family belong to your medical scheme and the same medical aid plan or option.
Waiting periods and exclusions
As with conventional medical aid, waiting periods and exclusions apply to gap cover.
Typically there’s a general waiting period of three months for all benefits, as well as a 12-month waiting period for pre-existing conditions. During these waiting periods, you and your family are not eligible for cover.
Exclusions refer to certain procedures and treatments that are not covered by gap cover benefits. These vary according to provider. Typical exclusions include obesity treatment, cosmetic surgery and specialised dentistry.
Note that a gap cover provider may refuse to cover the costs of co-payments defined as percentages rather than rand amounts; claims that are older than six months; and any limit, co-payment, or penalty imposed on you by your medical aid scheme for non-compliance with scheme rules or authorisation procedures.
Why you should register for gap cover
To illustrate why gap cover is an essential add-on to your medical scheme benefits, consider some examples of common procedures and their costs, the amounts covered by a typical medical aid scheme and – if you don’t have gap cover – the amounts you’d be left to pay from your own pocket.
|Procedure||Actual cost||Medical aid payment||For your account|
|Hysterectomy||R 12 978||R 4 751||R 8 227|
|Coronary bypass surgery||R 40 752||R 13 588||R 1 959|
|Surgical wisdom teeth extraction||R 8 227||R 27 164||R 4 302|
*The values in the table are illustrative only; actual costs and medical aid contributions vary across providers.
For many, it may come as a shock to realise that even if you have medical aid, you could be faced with crippling medical costs if you or a close family member requires treatment for illness or after an accident.
Gap cover closes the gap, ensuring that you can afford the care that you and your family need.