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What is Gap Cover?

Many South Africans who have a medical aid policy, believe that it will cover all of their medical costs, should they be admitted to hospital or face a sudden serious illness. Unfortunately, in many cases, a medical aid policy doesn’t cover the full extent of expenses, and people are often left with a large financial shortfall between what the medical costs are and what their medical aids are willing to pay.

Gap Cover pays for any unexpected medical expense shortfalls related to hospitalization for accidents and illnesses, including when healthcare professionals charge more than what your medical scheme pays. The shortfall would then become an out of pocket expense. Provided that your procedure or treatment is paid from the Hospital Benefit of your Medical Scheme, Gap Cover will then pay the outstanding amount due. Therefore it pays the gap between what your medical aid covers and what hospitals and specialists charge.

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How does Gap Cover work?

Gap Cover pays for the ‘gap’ between what your medical scheme pays, and what a private doctor charges. If you break your leg and are booked into the hospital, your medical aid covers your hospital stay, doctor’s fees, anaesthetist’s costs, medicine and supplies. However, your medical aid will only cover a certain percentage depending on your plan – in this example it will cover 100%. This means if your doctor and anaesthetist charge a rate at 300%, you will be liable for the shortfall of 200%. That’s where Gap Cover comes in – it covers the shortfall so that you are not affected financially.

What is the cost range of Gap Cover compared to the cost range of what it may cover? 

The cost range of Gap Cover may vary between different insurance providers. Monthly premium costs can be anything from R200 per family, per month to R600 per family, per month. The maximum amount that will be paid towards in-hospital expense shortfalls is calculated at five times (or 500% of) the medical scheme rate defined by your medical scheme. This then covers up to R164 000 per insured per annum, according to the Overall Annual Limit (OAL) – the maximum amount that may be claimed by either member of the family unit.

Who should take out Gap Cover?

If you have medical aid or are considering joining one, you should have Gap Cover to complement it. Medical procedures can be expensive and if you don’t have sufficient protection in place this can lead to life-changing debt.

Do I have to take out my Gap Cover with the same Insurance provider as my medical scheme?

Gap Cover is a separate product and can be taken out with a different insurance provider, not necessarily the one of your medical aid. If you do not have medical aid, you will not be able to take out Gap Cover