Gap Cover Shortfall Solutions  

December 18, 2021

Medical gap shortfall is something a lot of people are unaware of when taking out a Medical aid plan.

They are under the impression, that if they are members of a medical aid, then they have cover for anything relating to medical conditions.

But they experience a rude awakening when, after a stint in hospital, the bills start rolling in. And they get angry when they see they do not have 100% cover as their medical aid had promised.

Your Medical Aid Does Not Keep its Promise – So What Happened?

The medical schemes follow the NHRPL (National Health Reference Pricing List) when they set their tariffs. Each medical aid may have their own tariff which is referred to as MSR. (Medical Scheme Rates)

When your medical aid states that they pay 100% of MSR, then they mean just that. They pay 100% of their tariff for a particular medical service.

The problem comes from the medical practitioners, who charge whatever they wish, some of them up to 5 times the MSR. The shortfall brought about by this imbalance, must be paid out of your own pocket. This is what is called Medical gap shortfall – and this is where Gap Cover becomes essential.

What is gap shortfall and How does it Benefit Me?

•  Gap Cover or Shortfall Cover, pays the difference between what the health professionals charge, and what your medical aid is prepared to pay.
• Gap Cover is a short-term insurance, so only companies that have a licence to sell insurance may sell this cover.
• Some medical aids, who are insurance companies as well, have their own Gap Cover.
• To get cover, you must be a member of a medical aid.

So what Does gap Shortfall Cover cover

There are many companies offering Gap Cover such as Zestlife. Guardrisk Insurance Company Ltd underwrites the policy.

Zestlife is an excellent Gap Cover provider. They pay up to 500% of the MSR. They have two options available, with very affordable premiums:

 

 

There are no general of condition specific waiting periods with Zestlife. BUT no benefits are payable for a period of 12 months if within the 12 months before the start date of the cover, medical advice, diagnosis, care or treatment was received or would have been recommended.

Zestlife regards pregnancy before the start date of the cover as a pre-existing condition.

Generally gap Shortfall Cover offers –

• In-hospital Cover. You have cover for any specialist, doctor, or radiology shortfalls. There is an annual limit on this.
• Out-patient Cover. You have cover for about 50 procedures done in or out of hospital if a shortfall occurs.
• Co-payments. For hospital admissions, scans and certain surgical procedures.
• Cancer Cover. Covers shortfalls on cancer treatments. There is a maximum annual limit that applies.
• Internal Prosthesis. Hip replacements, knee replacements, will have a maximum limit that applies.
• Casualty Cover. Charges associated with any admission to the casualty department of your hospital, in connection with an accident, will be covered.
• Dental Cover. Any dental work after an accident will have the shortfall covered.
• Accidental Death and Disability Cover. Usually, the gap cover will pay a lump sun. A premium waiver valid for 3 months, is often also applicable.

 

For gap cover you no medical examination, premiums escalate annually and the cover includes no day to day medical costs.

For as long as medical aids base their tariffs on NHRPL, we need Gap Cover and it has to be good. So take a chance on Zestlife – at least you know you have the best there is!

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

All info was correct at time of publishing