What is Gap Cover for Medical Aid?

March 3, 2022

Private medical care across the world can be quite expensive. South Africa is no exception to this – medical aid and private medical care account for a large part of every individual’s budget. So what is gap cover for medical aid?

There is often a perception that all medical bills have coverage by a medical scheme when a person is a medical aid member. However, this is not always the case. Some medical bills may go unpaid by the medical scheme.

Gap cover can fill the void left by a medical aid which does not fully pay medical accounts.

Partial payment by medical aid

Many medical aids will pay only a partial amount of a medical bill. There is also the possibility that the medical scheme does not cover any part of the bill, which is a huge blow for a client, especially if this is only clear once commencing treatment.

Certain doctors, treatments, therapies and medications will not be covered by the medical aid. It may happen that the fees of a private doctor are higher than the agreed payment amount of the medical scheme. Some doctors may prescribe medications not covered by the medical aid.

What is Gap Cover For Medical AidThe part of the account that the medical scheme is not willing to pay then becomes the responsibility of the individual member.

The member can attempt to get the medical aid to foot the rest of the bill. Alternatively, the medical practitioner can give a discount or accept installment payments from the client. There is a very small chance that either of these options could become a reality.

Very few people will have the extra money lying around to pay for medical accounts, especially if the bills are for large amounts of money. Delving into savings is seldom an option for the everyday person.

Many people then question how to pay the remainder of the account, which could amount to a high value. Bills will also stack up quickly if there are payment problems for several treatments and medications. This is where gap cover comes into the picture.

Gap Cover – What is Gap Cover for Medical Aid

The portion of the medical account that the medical aid does not pay can be called a “gap” – an opening or void that needs to be filled in some way – which needs to be paid.

Gap cover for medical aid will pay for the difference between the amounts charged by the medical practitioner and the amount that was paid by the medical scheme.

Gap cover usually only applies to treatments and services done in-hospital. However, many gap cover options now provide additional support to members. This support may also cover certain out-of-hospital treatments, medications, and therapies.

Gap cover has a monthly premium, just as with medical aid, but at a much lower rate per family. Taking out gap cover will help to pay for unexpected hospitalisations and other medical costs. Gap cover is a safety net for those with frequent or unexpected medical expenses.

Complete the form on this page and click on the “Get a Quote” button to get a Gap Cover quote.

All info was correct at time of publishing