When do medical aid members need gap cover?

December 11, 2021

The cost of private medical care often becomes high for medical aid members in South Africa. So when do medical aid members need Gap Cover?

Medical aids often do not pay the full medical account and leave the rest of the account for payment by the individual member.

This may not be a problem if the individual has been able to plan for the additional expenses. But emergency medical care may result in large unexpected accounts.

Medical aid rates and gap cover

The medical aid sets an annual rate at which medical practitioners charge for different treatments. However, top medical aid plans will often pay for the treatment at a higher rate, for example, 300% of the base rate. Medical professionals may charge a medical aid rate of 400%, leaving individuals to pay the remaining 100%.

So when do medical aid members need Gap Cover? This is where gap cover can help a medical aid member. Gap cover can supplement medical aid by covering the rest of the account, which goes unpaid by the medical aid. The gap cover insurance will then pay the other 100% of the account, known as the tariff gap.

When Do Medical Aid Members Need Gap Cover

The tariff gap created can have coverage by a gap cover provider at up to 500% of the rate determined by the medical aid. In most cases, the account will then be paid in full and a further contribution is not required by the member.

Benefits offered by gap cover

Gap cover consists of cover for in-hospital treatments and additional benefits. Gap cover is only applicable to medications, treatments and procedures that have coverage by your medical aid plan. Any treatment which is not on a medical aid plan will also not be on the gap cover insurance.

It is beneficial to opt for a higher plan for gap cover as it will then pay for more additional benefits. Certain gap cover insurers will pay for dental procedures, usually in-hospital, at an additional cost.

Certain gap cover insurers will also pay the co-payment, which is usually the responsibility of the medical aid member. Medical aids do not pay for the co-payment thus is an added benefit of gap cover.

Some medical aids also place a cap on the cost of certain procedures. This is known as a sub-limit. Once the sub-limit is attained, the sub-limit gap cover will kick in and will pay some, or all, of the remaining medical account.

An oncology benefit exists for some gap cover options. The oncology benefit may assist with cancer treatments, even if done out-of-hospital. Certain co-payments will also be available for this benefit. Medical aids do not cover experimental medication for cancer; however, the gap cover can pay for this.

When do Medical Aid Members need Gap Cover – More Benefits

Gap cover is a benefit to have, even with a solid medical aid. Unexpected treatments, emergencies, medications and co-payments gave coverage on most gap cover options. The further cover may include dental treatments, payments for oncology, and experimental treatments and medications. The additional expense per month is affordable when considering the cost of benefits provided by gap cover.

Fill in the form on this page with your details and submit them to get a Gap Cover quote.

All info was correct at time of publishing