How to assess a medical gap policy

December 16, 2021

A medical gap policy protects you from having to make medical aid co-payments. That is, the difference between your medical aid’s stipulated tariff rate and the amount actually the medical profession charges.

There are few, if any, South African medical schemes that pay 100% of your healthcare costs. Yes, these schemes do say that they pay 100%. However, that represents their tariff rates and not the fees imposed by members of the medical profession. And they can charge up to 500% more for their services.

Medical Gap policy – Read the fine print

You will save yourself a lot of heartache by reading and thoroughly understanding your medical aid policy. There are numerous clauses that makes this task onerous so get advice from a consultant at your medical scheme or discuss Gap Cover with an insurance broker. These services are free of charge and could end up saving you a ton of money. Remember, forearmed is forewarned.

Medical Gap policy – Filling the Gap

How a Medical Gap Policy Works

All medical aid schemes have exclusions and limitations in their fine print – those are medical procedures and/or treatments they do not cover or for which they offer limited benefits. These conditions vary from one medical scheme to another.

Gap Cover is offered by many South African insurance companies such as:

  • Ambledown
  • Complimed
  • Discovery
  • Stratum

Do your research and select your Gap Cover provider carefully. The insurance you select must be able to fill the gap between shortfalls in your medical aid’s benefits and payouts.

As previously stated, your medical scheme’s 100% payout probably equates to no more than one-third of the end cost of your medical treatment and, in several instances, could only represent a fifth of the cost of your final medical bill.

The reason for this is simple. Medical practitioners rarely, if ever, stick to the tariff rates stipulated by medical aid schemes and the person who has to foot the bill for the difference in these amounts is you, the principal member of the scheme. And that’s where Gap Cover comes in – it pays that difference.

Medical Gap policy – So little for so much peace of mind

Gap Cover short-term insurance is really very affordable and, when you think about the peace of mind it offers, your monthly premiums is money well-spent.  You could face a shortfall of over R100,000 for a hospital procedure. No one has that kind of cash in their bank account. Gap Cover will pay it, leaving you home and dry.

There is no doubt whatsoever that Gap Cover has become an essential product to boost our healthcare portfolios and anyone who is a member of a registered South African medical aid scheme qualifies for this form of short-term insurance.

Medical Gap policy – Other Gap Cover benefits

You claim for gap payments after your medical aid scheme has paid its contribution for your medical care such as a hospital procedure or treatment. Your Gap Cover provider will then pay the difference of any outstanding amounts.

You can also downgrade the benefits in your medical aid scheme to save money that can then be used towards your Gap Cover monthly premium – just ensure that any downgrades are adequately covered by the benefits of your new short-term insurance policy.

You can find the Medical Gap Cover policy to best suit your personal needs by researching online and filling in the form on this page will ensure that you receive a  quote tailored to your specific needs.

All info was correct at time of publishing