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Why you should consider gap cover

By Isabelle Coetzee

Your medical aid should protect you from incurring large medical bills when you’re sick. But what if your plan doesn’t cover the full cost of your medical expenses?

This is where gap cover kicks in. It settles the outstanding amount that your medical aid doesn’t cover. We got in touch with insurance experts to find out whether gap cover is worth having.

Tip: Don’t have a medical aid plan? Find out more on this page and get a quote by filling in the form.

How does gap cover work?

According to Travys Wilkins, CEO of CompareGuru, gap cover is an insurance product that compliments most medical aid plans in South Africa.

“It’s key to note that GAP cover doesn’t provide replacement cover to medical aids. Gap cover serves to cover certain potential shortfalls in medical aid coverage,” says Wilkins.

“An example would be the specialists’ fees for childbirth, where most medical aid rates are around R4,000, but the actual cost is around R20,000 in a private hospital. These types of shortfalls are covered between two and six times (200-600%) the medical aid rate, depending on the GAP provider and cover option selected,” he explains.

Wilkins points out that gap cover only pays a claim where the medical aid has paid its liability under the claim. In other words, gap cover won’t pay for treatment that is excluded by the medical aid.

Martin Neethling, head of Sanlam Health Insurance and Distribution, agrees that gap cover is designed for people who’re already members of a medical scheme.

“The product aims to pay the ‘gap’ or shortfall between what your medical scheme pays, and what a service provider charges. Gap cover follows the scheme rules, in terms of benefits, and will only pay when the scheme approved payment of a certain benefit,” says Neethling.

READ MORE: Medical aid plans and hospital plans: What’s the real difference?

What are the costs compared to the gains?

Wilkens explains that the cost of gap cover can vary from R99 to R600, depending on individual, family, and senior rates, and that they generally all focus on these main “gaps” in medical aid plans:

  1. Shortfalls in hospital due to specialist fees exceeding 100% of medical aid rates. As mentioned, this cover ranges from 200% to 600% of medical aid rates.
  2. Co-payments or deductibles, which are set amounts per defined procedure that the consumer is liable to pay towards the procedure – an example would be a R3,000 co-payment for an endoscope.
  3. Oncology shortfalls are available on your more expensive and comprehensive gap cover options, where co-payments and certain specialist treatment shortfalls are covered.
  4. Sub-limit shortfalls are also available on more comprehensive gap cover options, which includes coverage where you exceed a defined sub-limit, often limited to specialised areas like internal prosthetics.

Who should consider taking out gap cover?

Wilkins believes that everyone who can afford at least a basic medical aid plan should consider taking out gap cover.

“While most medical schemes are opposed to this piece of advice, rather opt for a decent hospital plan and a mid to comprehensive gap cover option. This is not only the most cost-effective structure but, for most people, also a sufficiently comprehensive combination,” says Wilkins.

Neethling agrees that most medical scheme members will benefit from this additional cover. He explains that some gap covers provide cover per family and will cover children if they’re also covered on the parents’ medical scheme.

“New-born babies need to be registered within specific time limits and are born onto the scheme and not underwritten. Most gap cover companies will impose 9 to 12-month exclusions on pregnancy with new applications. If you’re planning to have a family, it’s important to ensure that you’re covered ideally before falling pregnant,” says Neethling.

He adds that every medical scheme member should ensure they understand what they’re covered for by their scheme and what not, specifically relating to unique and anticipated healthcare needs.

He recommends considering the following when choosing a gap cover provider:

  • A reputable brand
  • Clear and understandable benefits
  • Benefit richness, specifically for the most probable risks (such as in-hospital and oncology shortfalls)
  • Benefits relating to specific planned procedures for your individual needs
  • Premium-to-benefit ratio compared to competitors in the industry
  • Quality of administration, service, accessibility and ease of doing business

Cover your medical expenses today by filling out this form for a medical aid quote.

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