Gap cover is designed to provide extra financial protection for individuals who already have medical aid. It covers the shortfall between the fees charged by healthcare providers and the tariff rates set by your medical scheme. By obtaining gap cover, you can safeguard yourself and your family from these financial gaps, helping to minimise substantial out-of-pocket costs for medical treatment.
Key Takeaways
- Gap Cover Provides Financial Protection: Gap cover bridges the gap between the Medical Scheme Tariff (MST) and the higher fees charged by healthcare providers, reducing the risk of substantial out-of-pocket medical expenses.
- Types of Gap Cover to Suit Diverse Needs: Options range from basic gap cover for essential in-hospital expenses to comprehensive plans covering co-payments, sub-limits, and specialised treatments, with tailored policies available for high-risk individuals.
- Choosing the Right Gap Cover: Selecting a suitable policy requires evaluating healthcare needs, budget, coverage benefits, waiting periods, and exclusions, along with ensuring compatibility with your medical aid scheme.
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What is Gap Cover?
Gap cover is a type of short-term insurance aimed at providing additional financial protection for individuals who are already covered by a medical aid scheme. Its primary purpose is to bridge the gap between the Medical Scheme Tariff (MST) and the actual fees charged by private healthcare providers.
In South Africa, medical aid schemes typically reimburse doctors and specialists at rates of 100%, 200%, or 300% of their scheme tariffs. However, private medical practitioners often charge significantly more, sometimes as much as five times the standard tariff.
With gap cover, you safeguard yourself and your family from this financial shortfall, reducing the risk of incurring substantial out-of-pocket medical costs.
Gap Cover Benefits
Certain gap cover products provide coverage for both in-hospital expenses and specific out-patient costs. These may include covering co-payments associated with hospital admissions, selected surgical procedures, and medical scans.
Many medical aid schemes in South Africa require members to pay co-payments when they use hospitals outside the scheme’s designated network. Gap cover assists by covering these mandatory co-payments, often up to a specified limit per family each year.
Appropriate gap cover may also offer lump sum benefits to address expenses related to the medical treatment of specific cancers, internal prostheses, accidental dental procedures, as well as treatment and care received in a casualty ward.
Types of Gap Cover
Gap cover policies vary in scope and benefits, catering to different needs and financial circumstances. Below are the main types of gap cover available in South Africa:
Basic Gap Cover
Basic gap cover provides limited benefits focused on covering the shortfall between the Medical Scheme Tariff (MST) and the actual fees charged by healthcare providers. It is ideal for individuals with straightforward medical needs who require protection against in-hospital expenses. Premiums for basic gap cover are generally more affordable, but the coverage may exclude out-patient treatments or additional co-payment benefits.
Comprehensive Gap Cover
Comprehensive gap cover offers an extensive range of benefits, including coverage for both in-hospital and certain out-patient expenses. In addition to addressing tariff shortfalls, it typically covers co-payments, sub-limits on specific treatments, and costs for procedures such as internal prostheses or specialised cancer treatments. This type of policy is suitable for families or individuals with complex healthcare requirements, though premiums tend to be higher compared to basic gap cover.
Specialised Gap Cover for High-Risk Individuals
Some insurers provide tailored gap cover policies for individuals deemed high-risk, such as older individuals or those with chronic medical conditions. These policies may include enhanced coverage for high-cost treatments, specialised care, or additional support for managing pre-existing conditions. However, they often come with higher premiums or stricter underwriting criteria.
Comparison of Gap Cover Providers in South Africa
Choosing the right gap cover provider is an important step to ensure adequate financial protection against unexpected medical expenses. Below is a brief overview of some of the leading gap cover providers in South Africa, highlighting their offerings and unique features.
| Provider | Key Features | Unique Selling Point |
|---|---|---|
| Stratum Benefits | – Multiple gap cover options (basic to comprehensive). – Covers in-hospital shortfalls, co-payments, and sub-limits. – Optional add-ons for cancer and specialised treatments. | Customisable plans to suit diverse individual or family needs. |
| Zestlife | – Covers shortfalls up to 500% of the medical aid rate. – Includes co-payments, sub-limits, and accidental dentistry. – Lump-sum payouts for cancer and critical illness costs. | Affordable plans with a focus on high-cost treatments, particularly cancer care. |
| Complimed | – Covers in-hospital shortfalls, co-payments, and emergency casualty costs. – Benefits for sub-limits on joint replacements and internal prostheses. – Emphasises affordability and accessibility. | Family-focused plans with comprehensive dependent coverage at reasonable costs. |
| Ambledown | – Offers a wide range of plans addressing in-hospital shortfalls and co-payments. – Includes sub-limit cover for procedures and casualty treatment. – Optional benefits for emergency treatment. | Oncology-specific benefits for enhanced cancer treatment coverage. |
| Sirago | – Covers shortfalls, co-payments, and sub-limits on high-cost procedures. – Benefits for maternity treatments and accidental injuries. – Enhanced oncology and casualty cover options. | Focus on maternity and family-specific benefits, including enhanced maternity coverage. |
How to Choose the Right Gap Cover
Selecting the most suitable gap cover policy involves evaluating several key factors to ensure it aligns with your healthcare needs and financial situation. Below are the primary considerations:
Assess Your Healthcare Needs
Start by reviewing your medical aid plan to identify potential gaps in coverage. Consider your health history, the likelihood of requiring specialised treatments, and whether you are at risk of incurring significant out-of-pocket expenses for hospital or outpatient care.
Consider Your Budget
Gap cover premiums vary depending on the level of coverage offered. Determine how much you can afford to spend on gap cover while balancing the benefits provided. Avoid policies with low premiums but insufficient benefits, as they may not address your specific needs.
Review the Policy’s Coverage
Examine the benefits included in each policy. Key aspects to look for include:
- Coverage for tariff shortfalls.
- Co-payment benefits for procedures or hospital admissions.
- Lump-sum benefits for conditions like cancer or accidental injuries.
Check Waiting Periods and Exclusions
Gap cover policies typically include waiting periods for new members, especially for pre-existing conditions. Review these timeframes and ensure you understand which treatments or procedures are excluded from the policy.
Consider Family Coverage
If you are covering your family, ensure the policy extends benefits to all dependents on your medical aid scheme. Verify age limits for dependent children and whether your spouse is included.
Compare Providers
Research different gap cover providers and compare their offerings. Pay attention to the overall reputation of the insurer, customer service quality, and claims processing efficiency.
Read the Fine Print
Carefully review the policy’s terms and conditions to avoid surprises. Ensure you understand the maximum limits, exclusions, and any additional requirements for claims submission.
Eligibility for Gap Cover
Individuals who are members of a recognised South African medical aid scheme and are aged 60 years or younger meet the requirements to qualify for gap cover.
The benefits also include coverage for a spouse and dependent children, subject to specific age limits. However, it is a requirement that all family members are registered under the same medical scheme and enrolled in the same medical aid plan or option.
Claims Process and Documentation for Gap Cover
Submitting a claim under your gap cover policy is a straightforward process, provided you follow the necessary steps and meet the required timelines. Below is a detailed guide on how to navigate the claims process effectively:
Obtain Relevant Documentation
To initiate a gap cover claim, you must gather all relevant documentation related to your medical treatment. This typically includes:
- The itemised account from the healthcare provider.
- The statement from your medical aid scheme detailing what was paid and what remains outstanding.
- A copy of the authorisation letter issued by your medical aid for the procedure, if applicable.
- Any additional supporting documents requested by your gap cover provider, such as proof of payment for co-payments or detailed medical reports.
Review Your Policy’s Coverage
Before submitting a claim, carefully review your gap cover policy to ensure the specific expense is covered. Pay close attention to exclusions, maximum benefit limits, and whether the claim falls within the stipulated waiting periods.
Complete the Claim Form
Most gap cover providers require a completed claim form, which can usually be downloaded from their website or obtained directly from the provider. Ensure all sections are filled out accurately, including personal details, medical aid information, and details of the healthcare service.
Submit the Claim
Submit the claim, along with all the required documents, to your gap cover provider. Claims are typically submitted via email, an online portal, or, in some cases, by post. Be sure to keep copies of all documents for your records.
Monitor Claim Progress
After submitting your claim, monitor its progress by following up with your provider if you do not receive an acknowledgment within a reasonable timeframe. Most providers will process claims within 7 to 21 working days, but this can vary depending on the complexity of the claim.
Waiting Periods and Exclusions
Similar to traditional medical aid, gap cover policies include waiting periods and exclusions. Generally, there is a standard waiting period of three months during which no benefits are provided, as well as a 12-month waiting period specifically for pre-existing conditions. During these waiting periods, neither you nor your family members will qualify for any benefits under the gap cover policy.
Exclusions refer to specific procedures and treatments that are not covered by gap cover. These exclusions differ between providers, but common examples include treatments for obesity, cosmetic surgeries, and specialised dental procedures.
It is also important to note that some gap cover providers may decline to pay for certain expenses. These may include co-payments that are calculated as percentages rather than fixed rand amounts, claims submitted more than six months after the procedure, and any costs, penalties, or co-payments imposed by your medical aid scheme as a result of not adhering to their rules or authorisation requirements.
Conclusion
Gap cover is an essential financial safeguard for South Africans with medical aid, ensuring protection against unexpected medical expenses that exceed medical scheme tariffs. By understanding the types of gap cover, the benefits offered, and how to choose the right policy, individuals and families can make informed decisions to minimise financial strain during medical emergencies. Whether opting for basic or comprehensive gap cover, careful consideration of your healthcare needs and budget will help secure a policy that offers peace of mind and robust protection.
Frequently Asked Questions
What does gap cover actually pay for?
Gap cover pays for the shortfall between the fees charged by private healthcare providers and the reimbursement rates of your medical aid scheme. It also covers co-payments, sub-limit shortfalls, and specific expenses for certain treatments, depending on the policy.
Can I get gap cover without having medical aid?
No, it is designed as a supplementary product and requires an active medical aid scheme. It does not function as a standalone medical insurance policy.
Are there waiting periods for gap cover?
Yes, most gap cover policies include a three-month general waiting period and a 12-month waiting period for pre-existing conditions. These timeframes may vary between providers.
Does gap cover include out-patient treatments?
Some comprehensive gap cover policies include specific out-patient benefits, such as covering co-payments for scans or selected procedures. Basic gap cover typically focuses on in-hospital expenses only.
How much does gap cover cost?
The cost of gap cover can differ based on multiple considerations, including the service provider, and individual circumstances, such as age or family size. Premiums generally range from a few hundred rand per month for basic plans to higher amounts for comprehensive policies.
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