Why Gap Cover is Essential

December 15, 2021

Gap Cover is essential low-cost-high-value short term insurance. It covers the gap between what your Medical Aid will pay, and what health professionals charge. It also covers your hospital procedures and surgery.

Gap cover is not a medical aid. But you do have to belong to a medical scheme to take out gap cover. However, even though you may change your medical aid, you may still keep your same gap cover.

Monthly premiums start at about R140. However, depending on what option you choose, premiums can be R250 and sometimes even more.

ONLY Medical aid members can apply for one FREE medical gap cover quote NOW by completing and sending the form on this page

Why Gap Cover is Essential – The Crux of the Matter

  • Gap Cover is Essentialpeople think if the medical aid says it pays 100% of their hospital stay, it means just that – they will pay all accounts in full. What a shock when they realise that is not the case at all.
  • The medical aids must by law pay out at specific amounts for any given situation. That list  is the  “Scheme Tariffs”, for which they will pay 100%.
  • The doctors, specialists, hospitals and other service providers, however, do not have to charge these tariffs, so they may charge whatever they wish. That is usually up to 300% -400% over and above the medical aid rates or tariffs.
  • You will not have cover  for all the medical accounts received after an unexpected or unplanned for a stay in the hospital, with perhaps major surgery.
  • If the medical aid pays 100% of the Scheme Tariffs and the specialists and surgery have charged 300% of these rates, you can imagine the enormous shortfall you are left to pay from your pocket.

Examples of Procedures and Shortfalls

  • tonsillectomy – R5 398.17
  • triple Bypass – R27 164.20
  • MRI Scan with anaesthetist – R5 398.17
  • appendectomy – R2 053.26
  • caesarian section – R8 413.20
  • wisdom teeth removal – R4 301.81

So if you don’t have gap cover, you are likely to have a significant shortfall to pay, should you land up in a hospital. You could find yourself in dire financial straits without gap cover.

The Advantages of having Gap Cover

  • You will be able to choose the best surgeons, physicians, or other specialists, without worrying about paying the medical aid shortfalls out of your pocket.
  • your gap cover will pay the difference, in some cases up to 500% of the scheme tariff.
  • Your gap cover will provide essential cover for your Co-Payments. That is the portion you have to pay for the cost of certain investigative procedures, hospital admissions, MRI scans, back surgery, and others.
  • You will also have cover for in-hospital recovery, maternity, and oncology benefits.
  • Cancer treatment – medical aid pays a limited amount towards Chemotherapy, Radiation, and Cancer Drugs. Gap Cover provides an additional amount to assist with shortfalls on these treatments.
  • Gap cover will pay for emergency room visits, regardless of whether admission or not.
  • Your gap cover provider refunds you directly into your bank account, so you will be able to pay your shortfalls yourself.

Submit claims to your gap Cover provider after the Medical Aid has paid your service providers. Medical Aid statements, and specialists and hospital accounts must accompany your claim form.

There are waiting periods and exclusions with gap cover – the waiting period is usually 3 months before you can make a claim. Maternity benefits have a waiting period of 9 months while pre-existing conditions have a waiting period of 12 months.

Don’t Be Caught Off-Guard

Gap Cover is essential! It is a great help when there is an unplanned hospital admission, which could cause a financial shock.

ONLY Medical aid members can apply for a medical gap cover quote NOW by completing and sending the form on this page

All info was correct at time of publishing