The Basics of Gap Cover in South Africa

December 19, 2021

What are the Basics of Gap Cover in South Africa?

  • Every medical aid lays out standard rates for procedures.
  • When you have one of those procedures, the medical aid pays out according to its standard rates.
  • What can, and often does, happen, is that the medical bills are a lot higher than that rate.
  • You, as the consumer, are then expected to pay the difference.
  • Gap cover pays that difference for you.

In South Africa, we have a love-hate with our medical aids, don’t we? We need them, there is no question of that, but good cover is expensive. And, when you are paying a large chunk of your salary over to a medical aid, you expect them to provide the cover you are entitled to.

The problem is that there can be a serious disconnect when it comes to what you think you are entitled and what the rules of the medical aid say are the basics. And this is something that catches a lot of people out, especially when it comes to hospital stays. Members sometimes find that their medical aid does not even cover the basics.

Basics – What Is the Disconnect?

In all honesty, it’s not that the medical aids are trying to con us at all. They need to manage the funds that they receive so that all members are able to draw on them when they need to. In order to manage the fund properly, the medical aid Basics of Gap Insuranceneeds to set limits on the amount that it pays out per procedure.

They do this by working out in advance how much they will pay per procedure.

The disconnect comes in when the medical professional that you see charges more than this rate. And, as they are entitled to charge what they like, this can be substantially more. It is not uncommon for someone to find themselves being charged two or three times more than what the medical aid will actually pay.

This is especially true when it comes to hospital stays and specialist doctors and surgeons.

What Can be Done?

Should we change the basics? Should we all start demanding that the doctors charge less? That would be nice but it is not always practical. The higher the quality of care, the more you can expect to pay. And, if you want good medical care, you must expect to pay for it.

Among the basics you can do is to find gap cover that will fill in the difference for you when you need it.

Basics – What are the Basics of Gap Cover?

This is a specialized insurance product that is designed to pay the portion that your medical aid does not. So, let’s say that the surgeon sends you a bill for R10 000 and the medical aid only pays R6 000. Instead of you having to come up with the remaining R 4 000, the gap cover will pay it for you.

Are There Limitations on Cover?

Naturally, gap cover is also never going to provide endless cover. The policy will normally pay double or triple the standard medical aid rates. Some even go as far as paying five times the annual rates. They will also usually impose sub-limits, limits per family and annual limits for cover as well.

All in all, though, gap cover will generally cover you when you need it most.

Next step: Please complete and submit the form on this page to sign up for gap cover

All info was correct at time of publishing