What Everybody Needs to Know About Gap Cover

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Most of us have heard of Gap Cover before, but what is it exactly? 

What is Gap Cover?

Gap Cover is a short-term insurance product, totally separate from your medical aid.

Gap Cover is designed to compliment your medical aid policy by re-insuring the potential shortfalls for approved in-hospital procedures.

Comparison Between Different Gap Cover Providers

There are many different Gap Cover providers in the market with many different types of cover.

Trying to compare these various providers might get a bit tricky as there is just so much to compare.

That being said however, in this article we will look at the cost and benefits of the most basic cover, including: 

  • Shortfalls on doctors’ accounts (ONLY)
  • Senior Member GAP cover

COMPLIMED
GAP COVER

PSG CARE
GAP COVER

STRATUM
GAP COVER

Shortfalls on Doctors’ Accounts

Covers shortfalls on doctors’ accounts above scheme rate.

Benefit is unlimited.

Covers shortfalls on doctors’ accounts above scheme rate.

Benefit is unlimited.

Covers shortfalls on doctors’ accounts above scheme rate. 

Benefit is unlimited.

Health Rate Enhancer 400

Up to 500%: R121

Care

Up to 500%: R108

Base 500

Up to 600%: R99

Unique Benefits

If your budget is limited, choose less cover at a more affordable rate

Health Rate Enhancer 300

Up to 500%: R94 

Health Rate Enhancer 200

Up to 300%: R72

Emergency casualty cover Shortfalls on in-hospital pathology and radiology

Gap Cover for Seniors

Covers shortfalls on doctors’ accounts above scheme rate. 

Benefit is unlimited.

Covers shortfalls on doctors’ accounts above scheme rate. 

Benefit is unlimited.

Covers shortfalls on doctors’ accounts above scheme rate. 

Covers co-payments.

Benefit is unlimited.

Health Rate Enhancer 70+

Up to 500%: R173

Care 60+

Up to 500%: R137

Senior 500

Up to 500%: R168

Co-payments up to R15000

[tip title=”moneysmart tip”]It’s important to look at the cover that’s offered under your medical aid carefully, as no medical aid will cover you 100% for everything. Furthermore, most schemes limit the amount of cover they offer for certain procedures, so do yourself a favour and scrutinise your benefits and make sure you understand what’s included in your cover.[/tip]

Pros and Cons of Gap Cover

PROS

CONS

You can rest assured that should an approved in-hospital procedure occur, you will most probably not be left with a large bill for your own account. There is a general 3-month waiting period and 12-month pre-existing condition exclusions on all Gap Cover options.
The different Gap Cover options are extremely affordable. Some Gap Cover plans also have a 12-month exclusion on a pre-defined list of procedures.


Gap Cover Case Study

Without Gap Cover you could be set back financially for quite some time. 

Look at the medical aid limits for prosthesis for example: it could be R20 000 or R30 000. What if your prosthetic device cost more than that?

What about co-payments on MRI or CT scans? Did you know that you would need to pay R2 750 per scan out of your own pocket?

However by self-insuring with a Gap Cover product, you will be able to enhance your current medical aid option and protect yourself from unforeseen debt. 

One of my clients is on Fedhealth Maxima Basis and needed to go for a knee replacement.

Her shortfalls and co-payments were as follows:           

Hospital Co-payments for Prosthesis: R6000
Prosthesis Shortfall: R11000
Specialist Account Shortfall: R15000

TOTAL SHORTFALL:

R32000       

Who really has R32 000 spare to pay for a procedure that you would have expected your medical aid to pay for in full?

The client definitely did not have the money lying around, but had to have the procedure…

LUCKILY she had Gap Cover in place!

PLEASE NOTE that the information herein is for illustrative purposes only and should not be regarded as advice. All information is subject to scheme rules, which can change at any time without any prior notice.

For more information, contact your medical aid advisor or visit the Gap Cover providers’ websites directly.

Tell us about your experience with Gap Cover in the comments below.

Not on a medical aid yet? Apply for a quote by completing the form below:

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About Author

Nelda Celliers is a medical aid advisor based in Cape Town. She has a Higher Certificate in Insurance through the Insurance Institute of South Africa. Nelda obtained her licenses from the Financial Services Board and Council for Medical Schemes to operate her own medical aid practice, Medical Benefit Advisors.