Gap cover is an essential element of prudent financial planning. Together with medical aid, it provides extensive cover for escalating medical expenses.
To ensure you and your family enjoy premium medical care, you have to choose a gap cover policy that offers the best possible benefits you can afford.
Why invest in a gap cover policy?
As we know, quality health care is expensive. Despite their best efforts, medical aid schemes in South Africa pay out well below the going rate doctors, specialists and private hospitals typically charge.
In the private health care sector, fees of five times the Department of Health’s guideline rates, as quoted in the National Health Reference Price List (NHRPL), are not unheard of.
If your medical aid has a major medical benefit of just 100 percent or 200 percent of the NHRPL, you'll need adequate gap cover to cover the shortfall.
Determining the best gap cover: maximum rate
So the first variable to consider when choosing the best gap cover policy for your family is the maximum rate, the stated percentage of the shortfall the provider is prepared to cover. You will, of course, have to pay a premium proportionate to the maximum rate.
Value-added benefits
In addition to providing gap cover for in-hospital procedures, co-payments and, in some cases, day-to-day medical costs and treatments, high-end gap cover policies offer all sorts of value-added benefits.
two examples are cover for non-network co-payments and premium waivers – ensuring that in the event of death or disability of the main member, your family will continue enjoying uninterrupted medical gap cover and the provider will cover the cost of your monthly premiums.
Waiting periods
Another important factor to take into account is the waiting period, the prescribed time limits during which you are not eligible for benefits. Ideally, you want gap cover to kick in as soon as possible.
Finding a provider that offers the shortest possible waiting periods obviously makes financial sense.
Quick-fire gap cover comparison
| Zestlife Universal | Sirago Ultimate | Stratum Elite | |
|---|---|---|---|
| Maximum Rate: legally capped at R150k per person pa | 500% | 500%
Hospital account shortfalls up to R5k, limited to 3 claims pppa |
500%
Not including specialised radiology |
| Day to Day Benefits | 500% for 50 defined treatments, including specialised radiology | 500%
Specialist consultations up to R5k, limited to 3 claims pppa |
500%
Not including specialised radiology |
| Co-payments | Full cover + non-network co-payment cover up to R8k, limited to one claim per policy per year + cancer co-payment cover of up to 20% | Full cover - admission fee limited to R5k per year; penalty fee up to R8 250 pa | Full cover for in and out of hospital procedures + one co-payment per policy per year at non-DSP facility |
| Additional Benefits | Emergency room, cancer-related breast reconstruction, internal prosthesis and in-hospital dentistry cover | Emergency room, cancer, sub limit enhancer, additional care, and appliance benefits | Oncology, oncology + cancer optimiser, casualty, sub limit and trauma counselling cover |
| Value-Added Benefits | Enhanced cancer, accidental dentistry, accidental death, search & rescue, life support machinery, trauma counselling, and medical scheme & gap premium waiver | Dental, premium waiver, and initial diagnosis cancer cover | Medical scheme and gap cover waiver, and accidental death |
| Waiting Periods in months | No general waiting period
Pre-existing conditions: 12 |
General: 3
Pre-existing conditions: 10 Pre-existing cancer: 12 |
General: 3
Pre-existing conditions: 6 Specified conditions: 10 Pre-existing cancer: 12 |
| Premiums per month | Individuals: R295 (≤ 55 yrs) R369 (55-64) R420 (≥ 65)
Families: R369 (≤65) R420 (1 or more ≥ 65) |
Individuals: R290
Families: R329 |
Individuals and families: R320 |
To help you find the best gap cover policy in terms of maximum rate, extra benefits and waiting periods, we compare the premium products from a few of South Africa’s leading providers.
At IFC, we specialise in finding our clients the most comprehensive and affordable health care cover. Contact us today, or simply browse through our gap cover overviews and request a quote online.
