As we touched in our first blog of the health series (link to first blog), access to good health care is very important.
Despite this, medical aid sometimes does not necessarily cover all the medical expenses you may find yourself liable for.
You do not want to find a big bill in your inbox during your recovery from a procedure because your medical aid only covered a portion of the costs. But don’t worry, there is a product that covers exactly that “gap”.
What is Gap Cover?
Gap cover is a short-term insurance product that provides extra protection for those who are already on medical aid.
It covers the shortfall between your medical scheme’s tariff (MST) and the actual rates charged by private healthcare professionals for in hospital procedures.
When you need a particular surgery to be performed, you need peace of mind. You want to be seen by a specialist, someone you can trust will take care of your procedure.
Medical aid schemes in South Africa currently reimburse doctors and specialists 100%, 200% or 300% of the scheme rate.
However, the doctors or medical professionals may charge up to 5 times the base tariff for the medical procedure.
This is where gap cover comes in. It will pay the difference between what the medical professionals charge and what the medical aid pays.
You have to remember, Gap cover cannot provide cover where medical aid does not pay towards a procedure or covers the full amount for a procedure.
We recently had a case where gap cover actually ended up paying almost ¾ of the total medical bill. At a small fraction of the medical aid price, it can be well worth the small additional expense!
Illustration of the importance:
PROCEDURE
Dental Procedure
Surgery
ACTUAL COST
R 12 000
R20 000
MEDICAL AID PAYMENT
R 5 000
R 14 000
AMOUNT YOU HAVE TO PAY YOURSELF
R 7 000
R 6 000
Gap cover would pay the amount that you will have to pay yourself. This will help you focus on healing rather than worrying about the medical expenses.
Top 5 Gap Cover Providers
Here are some of the leading gap cover providers in South Africa with a few of the basics of each of them:
Turnberry Gap Cover
Turnberry gap cover will cover charges that are above the recommended medical aid rate. They provide cover up to 500%. Some co-payments are also covered.
The overall annual limits with Turnberry are considerably high, meaning they will cover the gap for serious events.
The limits are R500 000 per person and R1 500 000 per family on the Pro-Care option. The Elect-a-Care Turnberry gap cover option offers R200 000 per individual and R1 000 000 per family.
There is a 3 month waiting period when taking out a policy.
All members receive R5 000 000 international travel insurance as a free benefit. However, medicines, theatre and ward fees plus materials and PMBs are excluded.
Sirago Gap Cover
Sirago has four gap cover products that cover the tariff gap at 300% or 500% of the scheme rate. Premiums range from R218 to R645 per family per month. There are also rates for individuals.
In addition to cover in-hospital, there are in-room and prescribed minimum benefits (PMB) benefits on all plans. The top-tier options include additional benefits, ranging from cancer cover to co-payments, admission, and penalty fee cover.
Ambledown Gap Cover
Ambledown has 13 gap cover products that offer different levels of cover. Benefits are paid at 300% or 500% of the scheme rate, depending on the product.
Premiums vary from R150 to R350 per family per month, and benefits are commensurate with the value of the monthly contribution.
The products have different maximum age limits, with the ‘Senior’ options accepting individuals aged 71 years and above. Pre-existing conditions are excluded, and there’s a 12-month waiting period on scopes and specified surgeries.
Stratum Benefits
Stratum Benefits is an award-winning provider that offers four gap cover products. Benefits are paid at 500% of the scheme rate on all the options, and premiums vary from R248 to R679 per family per month.
There is no maximum age limit and no claims limit. In addition to in-hospital gap cover, there’s casualty, trauma counselling, cancer diagnosis and road accident cover on all the options.
The more expensive plans have additional benefits such as cover for co-payments and accidental death benefits.
Exclusions are standard. There’s a three-month general waiting period and a six-month pre-existing conditions waiting period. For certain, defined procedures, a 10-month waiting period applies.
Zestlife Gap Cover
Gap cover is provided at up to 500% of the medical scheme rate, and contributions vary from R372 to R568 per family per month.
There is no annual maximum claims limit. In-hospital cover extends to over 50 procedures conducted out of hospital, and there’s cover for standard and non-DSP hospital co-payments on all ZestLife options.
The maximum entry age is 64 years. Exclusions are standard, there’s a 10-month waiting period on birth-related claims and certain procedures are not covered in full within the first 6 to 12 months.
As you can see, gap cover isn’t a particularly high monthly cost but can be instrumental in the case of serious medical emergencies and the huge costs that can be associated with it (and unfortunately not fully covered by your medical aid). Please get in touch if need us to help cover that gap!
Gap cover is a short-term insurance product that provides extra protection for those who are already on medical aid. It covers the shortfall between your medical scheme’s tariff (MST) and the actual rates charged by private healthcare professionals for in hospital procedures.
Waiting periods are periods during a membership where members have to continually pay their premiums however they have no access to claim any benefits. There are two types of waiting periods namely general waiting periods and condition-specific waiting periods.
These waiting periods are put in place to protect schemes from members that join them and make large claims shortly after. It prevents people from abusing the benefits of a scheme shortly after requiring medical attention. The general waiting period is 3 months and is used most of the time unless the scheme has a concession available for a limited period.
