Why Medical Gap Cover is Vital!

People often ask why they should pay extra for medical gap cover when they already pay for a medical aid plan.

It’s because of the vast difference between what your medical scheme will pay for hospital care and what the medical profession charges.

Your medical aid plan only pays out according to an agreed tariff whereas specialists are not bound by those tariffs. Gap cover bridges the cash difference between medical plan tariffs and bills from surgeons, anaesthetists and other professionals

Medical gap Cover pays for the Shortfall you Would have to Find

Medical gap cover

In fact, because specialists charge up to five times more than your medical scheme will pay, you have to find the cash shortfall. Gap cover softens the blow of this unexpected extra cost at a time when you most need it. Only members of an existing medical aid can buy Gap cover.

Here’s an actual claim example:

The anaesthetist charged the patient R3 770.90. for the cost of a Caesarian Delivery. Her medical aid paid out R1 482.65. as per their rate. Gap insurance paid in the difference of R2 288.25. This bill represented a 254% increase above the agreed medical aid payment tariff.

For the same procedure, the patient received a bill amounting to R8 833.20 from her gynaecologist. The medical scheme paid out R2 759.09 and Gap insurance paid in the difference of R6 074.11. This bill represented a 320% increase above the agreed medical aid tariff.

The total bill for this Caesarian Delivery amounted to R12 604.10. The medical scheme only paid R4 241.74 towards the total bill, therefore, Gap cover saved the patient a whopping R8 362.36. That amount equates to a saving of 297%.

Who qualifies for Gap cover?

  • You must be a member of an existing medical scheme
  • Gap cover will also insure your family
  • You can include other members depending on the company and product chosen

Are there waiting periods?

  • For all benefits there is a general waiting period of three months
  • For pre-existing medical conditions there is a waiting period of 12 months

What is not covered by a Gap policy?

This could vary depending on the firm and product chosen. However, gap cover does not pay for the following:

  • Obesity, including stomach stapling
  • Cosmetic surgery, excluding trauma or oncology treatments such as breast reconstruction after a mastectomy
  • Any co-payment that is defined as a percentage and not a Rand value amount
  • Penalties, co-payments or limits imposed by a medical scheme for non-compliance of their regulations such as using a hospital that is not included in the scheme’s network
  • Specialised dental care
  • Claims lodged more than six months after an event

How much does Gap cover cost?

This depends on the firm and product chosen, but a comprehensive medical gap cover plan can be obtained for less than R200 a month.

 

Make an informed decision

Apart from researching online, you should seek advice from a reputable broker. Speaking to insurance consultants can also go a long way to helping you decide.

Remember – This is not a medical scheme and the cover is not the same as that of a medical scheme. This policy is not a substitute for medical scheme membership.

Medical Gap Cover is not a Medical Aid or an alternative to a Medical Aid. It is an insurance policy designed to complement your current Medical Aid.

 

Complete and send the form on this page to get a free medical gap cover quote. Note: for medical aid members in South Africa only