Gap Cover Makes Up for Medical Scheme Shortfalls

November 24, 2024

Logic dictates that 100 per cent means 100 per cent. But, sadly, in the medical aid world 100 per cent more often means one third. Those are medical scheme shortfalls.

This is not gibberish. This is a fact. The 100 per cent that your medical aid scheme says it will pay is for a prescribed tariff rate. That rate DOES NOT relate to the actual fees imposed by members of the medical profession.

These tariff rates are  on the National Health Reference Price List (NHRPL). The Government’s Department of Health compiles the list. The NHRPL acts as a guideline to specialists and anaesthetists. However, these specialists do not have to adhere to these suggested price structures.

Medical scheme shortfalls – An example of 100 per cent becoming one third

Here is an example of what your medical aid’s 100 per cent actually means. It equates to one-third of the final medical bill is as follows:

The cost of a CT Scan undertaken in a hospital is stated as R2,575.90 according to the NHRPL. But your specialist charges you R7,727.70.

If your medical aid works according to NHRPL tariff rates, this amounts to 300 per cent more than your medical aid cover. This means a shortfall of R5 151.80 which you would have to fund out of your own pocket.

Medical scheme shortfalls – What is Gap Cover all about?

Gap Cover is all about covering you for the difference in what your medical scheme is prepared to pay for hospital procedures and treatments and what your medical professionals actually end up charging you for their services.

Without Gap Cover, you leave yourself vulnerable to possible financial ruin because, as we all know, the cost of healthcare services in South Africa today is anything but affordable! The medical profession basically has carte blanche when it comes to tariff rates and their exorbitant fees have been the root cause for medical aid premiums sky-rocketing out of the reach of a vast majority of South Africans.

Gap Cover, on the other hand, is extremely affordable with realistic monthly tariffs to give you and your family peace of mind.

Medical scheme shortfalls – Who qualifies for Gap Cover?

Unfortunately, there is a requirement to obtain Gap Cover and that is that you must be a member of a registered South African medical aid scheme.

However, there is nothing to stop you from downgrading your medical aid benefits to supplement your Gap Cover monthly premium. Just ensure that you have sufficient cover for all your medical needs.

At the beginning of April 2017, the Government’s new Demarcation Regulations for Healthcare came into force. These regulations govern the products on offer by health insurance companies‚ such as Gap Cover and Hospital Cash Plans.

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All info was correct at time of publishing