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What is Gap Cover

Gap cover is designed to pay the ‘gap’ or shortfall between what your healthcare provider charge and the rate your medical aid pays. It is the amount that your medical aid plan is willing to pay out for a medical procedure and is usually less than what a health practitioner charges – especially if you are using a provider outside of your medical scheme’s network. It is a short-term policy that works in conjunction with your medical aid and is a product that has been designed to provide extra protection for people who already have medical aid.

Some medical aid schemes within South Africa currently reimburse doctors and specialists at 100%, 200% or 500% of the scheme rate but professional medical providers could charge up to five times the base tariff.  By having gap cover, you are protecting yourself and your family from financial disparity and potentially avoiding significant out-of-pocket medical expenses.

Some gap covers’ even offer in-hospital and specified out-patient benefits and, in addition, may cover co-payments related to hospital admissions, certain surgical procedures and medical scans. In some cases it is possible for medical aid schemes to require a co-payment should members make use of hospitals outside the identified network of schemes. With gap cover, this co-payment is covered up to a certain amount per family per year and covers a portion of the co-payment that you are responsible for.

With suitable gap cover, you could also qualify for a lump sum benefit to cover the cost related to the medical treatment of certain cancers and treatment or care within a casualty ward.

Most people are not aware that doctors are not regulated in terms of rates, hence they are able to charge over and above your medical aid rate. Your medical aid will also only provide cover according to the scheme rate and this is where gap cover comes into play.

Only when you experience a shortfall, co-payment and sub-limit do you realise gap cover is a much-needed safeguard, so it is advisable to take the pro-active approach rather than the reactive approach and apply for gap cover as waiting periods still apply from your first day of cover.

It can be easy to think that the terms Medical Aid, Medical Insurance and Gap Cover refer to the same thing, although they all serve to help individuals afford medical care, there are subtle differences.

As mentioned, waiting periods and exclusions apply to gap cover. Typically, there is a general waiting period of three months for all the benefits and an additional 12-month waiting period for pre-existing conditions and during this period you nor your family are eligible for cover.

For many, it may come as a shock to realise that even if you have a medical aid, you could be faced with crippling medical costs should you or a close family member require treatment for an illness or after an accident.

Gap covers close the gap, ensuring you can afford the care you or your family need. Contact Elixi to find a plan that suits you and your family.

The above information is not financial advice and should not be constructed as financial advice.

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