What is Medical Gap Cover and Why Is It Contentious?

December 11, 2021

Although you pay so much for medical aid each month, it can’t always pay your bills. That’s a shocker. Medical gap cover is there for you in these difficult times.

This means that people have to take out top up insurance – to make up what the medical aids can’t pay. But what is medical gap cover exactly? Read on.

The government sets a national pricing structure for all medical procedures. It is the National Health Reference Price List (NHRPL). Their mission is to determine the fair and reasonable cost of healthcare services in South Africa

ONLY Medical aid members can apply for one FREE medical gap cover quote. Just complete and send the form on this page

What Are Fair and Reasonable Prices These Days?

Say you undergo a medical procedure costing R5 000 but your surgeon charges R10 000. Then you will have to pay R5 000 out of your own pocket.

Gap-cover, therefore, caters for events where a medical scheme is not paying the full cost. That’s when a professional medical charges a higher rate than the scheme is willing to pay. This gap is a contentious issue that government has promised to address. However, nothing changes and medical Medical Gap Coverinsurers make gap cover available to complement medical aids.

What Is Medical Gap Cover – A Huge Move away from Medical Schemes

Today in South Africa, if  there was no gap cover it would mean more members leaving their medical schemes. That’s because they wouldn’t see value in purchasing monthly medical cover.

There have been different responses from Discovery Health and the financial services industry about the changes to gap cover. Discovery Health supports the proposed changes, while the financial services industry claiming the changes won’t benefit the consumer.

Discovery Favours the Elimination of Gap Cover

The major medical scheme Discovery Health says that these regulations will eliminate most gap cover and other health insurance products. That would be beneficial to individual consumers as well as members of medical schemes.

The financial service industry said that consumers spend millions each year on gap cover to ensure they are not out-of-pocket when using providers who charge more than medical scheme rates.

The financial service industry was concerned that government’s plans of cutting gap cover would leave this market out-of-pocket. They said that the government should address private healthcare costs, Prescribed Minimum Benefits (PMBs), as well as the tariffs suggested by the National Health Reference Price List (NHRPL).

There is debate around the health insurance industry, brokers and the companies that provide these products voting in favour of it.

The Council for Medical Schemes says that because there is no regulation of gap policies, they undermine the medical schemes industry. Health insurance products do have a role in the marketplace, but the products must complement medical schemes.

Gap Cover Policies are Legitimate

The contentions surrounding the matter of Gap Cover has given rise to much anxiety from employer groups and individual policyholders alike. Nonetheless, it is important to remember that Gap Cover policies are legitimate and legal.

In the absence of any mechanism which can cap the maximum charges raised by specialists in South Africa, Gap Cover is still the most affordable means of minimising exposure to inpatient specialist charges that may be many times higher than the cost of what your chosen medical scheme plan is prepared to pay.

Gap cover hasn’t been discontinued. Nothing has changed, and gap cover is still needed to cover the hospitalisation and medical costs that your medical aid does not pay out when you make a claim.

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

All info was correct at time of publishing