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Why Do I Need Gap Cover

One of the most frequently asked questions clients ask is “Why did my medical aid not cover the full cost of my hospitalization?” I thought I was covered for 100% of the costs.

Medical aid, being fraught with small-print, is a minefield for the regular person out there, who is just looking for the peace of mind that medical aid cover is supposed to give them. All you want to know is, as long as you pay your medical aid contributions, you will be covered in case of a catastrophe, such as a car accident, as well as for your normal day-to-day expenses at a healthcare provider. You definitely do not want to be bankrupted by additional costs you become aware of only after you are discharged from hospital. Additional costs which you can barely afford, and which are likely to put you back in hospital due to the financial stress you are now placed under!

In South Africa, medical schemes have different options from which you can choose, and these options vary in the benefits offered, and of course also the cost of the contributions. When choosing a medical aid option, you will see that professional services (such as the surgeon or anaesthetist) in hospital will be reimbursed at either 100%, 200% or 300% of the scheme rate. Now anyone will be forgiven for assuming that being covered at 100% means exactly that – you are fully covered! However, specialists in South Africa are not regulated as to what they can charge patients for their services, and could charge in excess of the 100% rate which medical schemes are willing to pay – sometimes as much as 500% of the scheme rate. The end result – the patient ends up with a short-fall on the specialist’s account, which he has to pay out of his pocket.

How Does Gap Cover Work?

Gap cover does not form part of your medical scheme membership – it is not even regulated by the same laws. While your medical scheme is regulated by the Council for Medical Schemes, and the Medical Schemes Act, Gap cover falls under the Short-term Insurance Act.

While your medical aid will reimburse the hospital or specialist directly when you are hospitalised, because of the regulatory issues, your Gap cover provider will refund you, the member, directly. It is then your responsibility to reimburse the service provider.

The process of claiming is also separate from your medical scheme. Usually, a Gap cover claim must be submitted after your medical scheme has paid the service provider. Having a Gap policy is also not dependant on a specific medical scheme. You can change medical schemes but still keep the same Gap cover. Because medical scheme membership is perceived as expensive in South Africa, many members think that by downgrading their medical aid and taking Gap cover, they will be paying less but getting more. However, there are some caveats. When downgrading your option, you might be sacrificing additional benefits not related to the in-hospital cover.

Contact Elixi for more information about how Gap Cover can help you

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