Does Medical Gap Cover Include Everything?

December 10, 2021

Gap Cover pays for the shortfall between what your medical aid pays and the actual charge. Does gap cover include everything your medical aid won’t pay, though? Depending on the policy, this can cover medical expenses in hospital. Or it may cover day to day expenses when you have reached your annual limit.

You may have come across a bill or two from a doctor that your medical aid would not pay. Or you may be blissfully unaware that you do not have full cover until you need to claim.

It is a common misconception that your medical aid will pay in full if you have a medical emergency that requires hospitalization. That is a misconception that costs many people dearly.

The medical aid may not cover certain specialist treatments. And, even if they do, they will often place a limit on the amount of cover that they provide. They will normally set these limits out as their standard medical aid tariffs.

Does Gap Cover Include Everything?

And, even when you have no annual limits relating to hospitalization, you could still have to pay a shortfall. Most specialists charge a lot more than the standard medical aid tariffs. That means that the medical aid might pay out following their agreement and leave you to pay the excess.

The schemes follow established medical aid rates. But there is no obligation on the part of the doctor to charge in accordance with these rates. (In fact, most doctors will say that these rates are insufficient.)

Does Gap Cover Include Everything

As crazy as it sounds, your medical aid will pay 100% of their prescribed rates, but the practitioner may charge 200% or even 500%.

In most cases, supply and demand determine prices. This sways prices in either the service provider’s or the consumer’s favour.

That’s Where Gap Cover Comes In

Gap cover has absolutely nothing to do with your medical aid and does not have to play by the same rules. You do not even have to take the cover with the same company that provides your medical aid.

Gap cover tends to be pretty affordable – with most plans coming in at less than R200 a month. And considering that the shortfall for a hospital stay could be thousands of rand, this is not bad. Does gap cover include everything? Yes, if you take out comprehensive gap cover.+

What Will Gap Cover Pay For?

In addition to being covered for a shortfall as a result of being charged a higher tariff, gap cover will also pay for other medical aid shortfalls.

Depending on the type of gap cover you take, you could also be covered for co-payments or deposits when it comes to hospitalization, co-payments as a result of not using a preferred provider and co-payments as a result of exceeding your limits.

Does the Gap Cover Pay the Bills?

Gap cover is paid out directly to you, and you need to pay the bills yourself. The main difference between this claim and the one sent to your medical aid is that you will need to provide proof of how much the medical aid paid out.

We recommend Zestlife for gap cover in South Africa.

To get a FREE gap cover quote, please add your contact details to the form on this page and submit. Remember that only medical aid members qualify for gap insurance.


All info was correct at time of publishing