When is Medical Gap Cover Necessary

December 9, 2021

Many people get a shock when, after a stint in the hospital, the bills start coming in. When they discover the amount their medical aid is not going to cover, the stress they experience can cause yet another set of health problems. They learn too late that medical gap cover is necessary to supplement your medical aid.

You could have a real financial crisis on your hands if you have realised that medical gap cover is necessary to pay the shortfall after an unexpected stay in a hospital.

These days medical schemes are paying out less, and members are paying in more.

Why Medical Gap Cover is Necessary

Most people think that their medical aid will pay most procedures, specialist visits,  hospital stays and surgical procedures in full, as they are covered 100%.

Unfortunately very few people realise that the medical aids have a regulated rate (the National Health Reference Price List – NHRPL) that they have to adhere to. So, if they say they will pay 100% of your

Medical Gap Cover is Necessary

stay in a hospital with all the procedures and specialist visits that go with it, they mean 100% of this medical scheme rate.

Specialists, however, are not under any obligation to stick to medical aid rates, as they have ‘contracted out’ of doing so. Therefore, they may charge what they like, which could be up to 500% of the scheme rate.

Look at the following example of a standard Caesarian Section –

Anaesthetist account R3,770.90

Medical Aid payment at 100%  R1,482.65

= shortfall R2,288.25

Gynaecologist account R8,833.20

Medical aid pays R2,759.09

= shortfall R6,074.11

The total cost of the operation is then R12,604

The medical scheme pays R4,241.74

The shortfall to come out of your own pocket is R8,362.36

So what is Gap Cover?

  • Gap cover does not form part of your medical aid, although you must be a member of one before you can take out the cover.
  • This type of insurance falls under the Short-term Insurance Act.
  • You submit gap cover claims after the medical aid has paid the service provider.
  • Premiums start at about R112 per month and can go up to R450 per month depending on the type and extent of cover you wish to take.
  • Different entry ages may apply, depending on the company you choose. Some only allow persons up to the age of 60, while others have no age limit.
  • Exclusions to payment of claims:

Self-inflicted injuries

Suicide attempts

Cosmetic surgery

Taking of recreational drugs and the consequences

Hazardous sports

Depression, mental illness, dementia, etc

Procedures that have been excluded by your medical aid

Day-to-day out of hospital consultations

  • Gap Cover is also known as Top-up Insurance.
  • It is a commodity of low cost, and high value.

Some health professionals send your account to debt collectors if you don’t settle in 30 days. This could affect your credit rating.

Some of the shortfalls your gap insurance will cover

  • Tariff gaps. This is the difference in what the medical scheme pays, and what the health professionals charge.
  • Co-payments. These are amounts not covered by the medical aid, like MRI scans, surgery, hospital admission fees, and certain procedures.
  • Sub-limits. These are limits on certain procedures as imposed by your particular medical aid.
  • Cancer Treatments. Most medical aids will provide up to an annual limit on the necessary drugs/treatments, radiation, and chemotherapy. But gap cover will provide an extra amount.

Medical aid is already expensive, and you may not feel you can afford another expense.

In our country the crime rate is high, and accidents occur every day. So don’t allow yourself the extra stress put on you by an unexpected stint in a hospital.

For peace of mind, rather take out gap cover today. It will protect you financially.

To request your medical gap cover quote, complete and send the form on this page

All info was correct at time of publishing