Gap Cover for Topmed Medical Scheme Members
December 10, 2021
Most South Africans are unaware that they have made a very costly mistake when it comes to medical cover until they end up in an emergency situation. Because even belonging to a big scheme like the Topmed medical aid might not cover your medical bills.
Think about this for a second – you end up in a hospital for a few days and undergo an operation. It’s no problem because you have an excellent medical aid.
Then you receive the bill for the shortfall, and you pretty much feel like going back to the hospital.
Think it won’t happen to you because you belong to Topmed medical aid?
Neither did Jane. She went in for a relatively routine operation and stayed overnight in a hospital. She has 100% cover, so she didn’t worry about the bill.
What she found out later, to her surprise, was that the surgeon who did the operation charged well-above medical aid rates. Her medical aid did pay 100% – of the medical aid rates.
That left her with a shortfall of R11 494 to pay out of pocket. She learned a very expensive lesson.
Does Jane Think Gap Cover Insurance is Necessary?
Before this incident, Jane had no idea what gap insurance cover was. She has since learned that if she had had one of these policies in place, she would not have had to find the R11 494.
That’s because gap cover covers the difference between normal medical aid rates and the amount that appears on the final hospital bill.
Medical gap cover is not something that you “should” have but can forget about if the budget is tight. Unless you have access to thousands or tens of thousands of Rands or know you’ll never need a hospital, it is essential.
The statistics are scary – specialists often charge at least double what the Topmed medical aid rates are. That leaves you liable for at least as much as your medical aid paid.
And the specialists and hospitals may set their fees structures. Some charge as much as 400% over medical ad rates.
For less than what you would pay for your coffee habit in a month, you can protect yourself against these potential fees. Isn’t the peace of mind worth it?
As a Topmed Medical Aid Member Do I Qualify?
Check against this checklist and see if you might qualify for cover:
- You are currently a member of a proper South African medical scheme.
- You are a dependent of the main member and enjoy the same level of cover. (Both would have the same the gap cover.)
- You are not 61 or older.
Do I Get Cover Straight Away?
As with most insurance products, there are waiting periods in place before you can claim:
- You cannot make any claims at all in the first three months.
- In the first year insurance firms will not pay claims relating to pre-existing conditions, such as heart disease.
- Claims relating to pregnancy will not be covered in the first year.
What Exclusions are There?
- Surgery to treat obesity.
- Cosmetic surgery that is not trauma or disease-related.
- Co-payments where a changeable amount is charged – for example, where you are charged a percentage of the sum and not a set charge.
- Cases where the excess is as a result of proper authorization procedures not being followed by you.
- Dentistry that is not related to tumours/cancers or trauma.
- Claims not handed in timeously – you have six months to put in a claim
Please complete and send the form on this page to receive your FREE gap cover quote
All info was correct at time of publishing