What Gap Cover Covers and What It Does Not Include
December 19, 2021
What gap cover covers and what do I get out of it?
- Cover for some out of your out of pocket medical expenses
- Better access to private healthcare
- An enhancement to your medical aid
- This is NOT a replacement for a good medical aid
- An affordable insurance product
Most of us, by now, understand that there can be a big difference between what portion of bills the medical aid pays and what we have to pay in ourselves. When it comes to private hospital costs, the shortfall can be staggering.
And that was why gap cover was introduced in the first place. The product was initially designed to cover any shortfall that the medical scheme didn’t pay. So, let’s say that the specialist came and saw you in the hospital and charged R1000 for the visit. If the medical aid paid R500, gap cover would have filled in the rest.
Gap Cover Has Changed Now
It was quite a good idea, but it wasn’t sustainable in the long-term. This is an insurance product, and the company needs to make a profit to sustain itself. But, according to a circular that Guardrisk sent out in 2016, gap cover was bearing the 
lion’s share of costs for hospitalisation.
What had happened was that you could get the least expensive option when it came to a hospital plan and not worry about the cover because the insurance would pay shortfalls. In reality, what this came to mean was that the insurers could pay as much as 80% of your hospital bill.
The companies had to start limiting what was paid out to remain profitable. Most payouts are now based on what the medical aid pays so, in consequence, the payouts are not limitless.
For the consumer, this means that, even with gap cover, you might be footing some of the bills yourself. How much will depend on the insurer your policy is through, your medical aid tariffs and the medical fees levied.
Stricter exclusions have also been put in place, limiting what gap cover covers.
What Probably Won’t Be Covered
This list differs between the different insurance companies and can also depend on the plan you have chosen. You can normally choose a basic plan that costs less but includes fewer perks. The more expensive plans will pay for many of these items.
- If you upgrade from a general ward to a private room
- Consultations that you underwent before being admitted
- In-hospital ward costs
- Some medications and prosthesis
- Medical appliances like crutches or wheelchairs
- Medical diagnostic exams like scans that are routine
- Costs for private or home nurses
- Weight-loss procedures
- Cosmetic dentistry
- Ambulance costs
- Costs for psychiatric disorders
- Cosmetic surgery for aesthetic reasons
- Costs if you choose a provider outside of the preferred provider network
- Co-payments as a result of a waiting period imposed by the scheme
What Gap Cover Covers
This is going to depend again on who your policy is with and which option you have chosen. It’s a good idea to read the policy documents (Yes, I know how boring this is) to see what will be covered. You might be pleasantly surprised.
- Most will cover in-hospital expenses for specialist services, such as surgeons
- Many will cover cosmetic surgery needed as a result of injury or illness
- Costs for emergency treatments
- Some cover for diagnostic scans
It is, in fact quite a long list of things that will be covered as well. The only way to know for sure is to check with your insurer. Gap cover is a valuable insurance and can serve you well as long as you acquaint yourself properly with the terms and conditions.
If you are a medical aid member, please complete and submit the form on this page
to get an accurate gap cover quote
All info was correct at time of publishing