Waiting Periods for Medical Gap Cover

December 18, 2021

There are waiting periods for medical gap cover. A competent medical policy advisor may be able to aid you in deciding on your gap cover needs, and the best products for you. While it’s hard to choose from the available gap cover options, some general pointers are:

Tariff gap protection

At the outset, gap cover policies filled in the difference between hospital specialist charges and your medical scheme maximum payout. This difference is known as a tariff gap.

Ever since the discarding of the guideline Waiting Periods for Medical Gap Coverhealth prices published by the Reference Price List (RPL). Most schemes came up with their tariff guides. These price guidelines are usually based on inflation adjusted pre 2009 RPLs.

Nowadays, gap covers usually fill in the gap between practitioner charges and insurance provider limits. All at the rate of two to five times the rate of the scheme.

Gap insurance providers are taking a different approach. Though Guardrisk has not put vast amounts of manpower into the determination of scheme payouts. It has also not focused on claim payment delays arising from waiting for scheme statements ascertaining the payout percentage per scheme. Revealed by Eales.

Guardrisk’s corporate risk solutions executive, Richard Eales says Guardrisk’s Admed policies settle claims based on the gap between specialist fess and the inflation adjusted, 2006 RPL (which came about through the Council for Medical Schemes).

Cover gaps for medical costs. Typically, gap cover protection does not compensate for the gap between a hospital by your scheme for your treatment and the hospital charges.

When gap cover doesn’t apply

Your insurance plan covers a large portion of the medical bill, although exceptions happen. Payment gaps come about should you visit a different hospital than one that is listed on your scheme hospital list (not applicable if an emergency). Or choosing a private ward over a general ward, if that is all your scheme pays out for.

There is no cover for some hospital charges by individual plans. Gap covers are to bridge the difference.

Gaps also occur should your total final hospital bill exceed your scheme’s overall annual limit. A gap cover that pays out the difference, such Hospital Excess by Complimed, is available. This kind of protection is known as top-up protection.


Out-of-hospital procedures – waiting periods for medical gap cover

Procedures that are carried out out-of-hospital cost gap cover.

As such, a number, but not every, gap cover provides protection against the difference between specialist charges and scheme limits when seeking defined outpatient procedures.

Complimed and Guardrisk, for example, offer gap policies on some procedures that settle the difference between specialist costs and scheme limits. These procedures comprise birth, various scopes, hernia repairs, prostrate biopsies, tonsillectomies, grommets, sinus surgery, renal dialysis and cancer.

Cancer cover gaps – Waiting periods for medical gap cover

Medical schemes, due to the increased number of cancer patients, have started limiting cancer benefits. In a bid to control spiralling claim payout costs, as well as newly developing treatments being prohibitively expensive.

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All info was correct at time of publishing