What is Gap Cover?
Simply put, Gap cover starts paying where your medical aid stops paying in hospital.
One of the most frequently asked questions is: “Why did my medical aid not cover the full cost of my hospitalisation?”
In South Africa, medical schemes have different options from which you can choose, with varying benefits. When choosing a medical aid option, you will see that professional services (such as the surgeon or anesthetist) 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 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 shortfall on the specialist’s account, which he has to pay out of his pocket.
To give an example of how significant these costs could be, have a look at this example of the cost of a caesarean section:
|Specialist||Cost||Scheme Rate (100%)||Gap Claim||%|
|Anaesthetist||R3 770.90||R1 482.65||R2 288.25||254%|
|Gynaecologist||R8 833.20||R2 759.09||R6 074.11||320%|
|Total||R12 604.10||R4 241.74||R8 362.36|
From the above, you see that if you belong to a medical scheme option which pays at 100% of the scheme rate, you would be responsible for a bill in excess of R8 000 for the birth of your baby!
Gap cover also offers a multitude of other benefits, which includes cover for co-payments on scopes and scans, as well as cancer-related benefits, such as cover for the co-payments above the medical scheme’s threshold.
How does Gap Cover work?
Gap cover complements your medical scheme membership. 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.
You can have a Gap cover policy with any South African medical scheme.
Your medical aid will usually pay the hospital directly for the cost of your hospitalisation. Your medical aid will also usually pay the doctors and specialists who treated you in hospital directly, but only at the medical scheme rate. Rates charged in excess of the medical scheme rate will be billed to you as the member.
You would then submit your claim to your Gap cover provider, who will refund you directly. It is then your responsibility to reimburse the service provider.
The value of having Gap cover cannot be stressed enough, even for members of medical scheme options that pay at 300% of the scheme rate.