What Gap Cover Will and Won’t Cover

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Together with medical aid, gap cover mitigates the financial risk associated with spiralling healthcare costs. It’s a form of insurance designed to cover the gap between what specialists charge and what your medical aid is prepared to pay.

Gap cover is especially useful for covering funding shortfalls for treatments and procedures conducted in-hospital.

In South Africa, gap cover is available only to existing members of medical aid schemes. The most comprehensive policies cover shortfalls for in-hospital medical expenses at up to five times the medical scheme rate.

How is gap cover paid?

Despite supplementary gap benefits, your level of medical aid cover is the key factor in determining whether the specialist and hospital accounts are to be paid in full.

If your medical aid benefits are paid out at 100 percent of the scheme rate and you have a gap cover policy that pays out two times (200 percent) the rate, you may still be personally liable for a portion of the costs.

As an example, medical aid pays out R8 500 on a R30 000 procedure conducted in-hospital. Gap cover of 200 percent pays out R17 000 (R8 500 x 2) leaving a payment gap of R4 500.

If the gap cover is paid at 500 percent the scheme rate, the procedure is covered in full, but the excess is not paid to the policy holder.

What is covered by gap cover?

Gap cover providers in South Africa offer a wide range of benefits that vary according to the type of policy you subscribe to. The following are the benefits.

Out-of-hospital benefits

In addition to picking up the funding shortfall for specialist consultations and in-hospital treatment, there is usually cover for certain procedures conducted in the doctors’ rooms and clearly specified in the policy.

Zestlife, for instance, funds the gap of more than 50 out-of-hospital procedures that include arthroscopies and colonoscopies, hernia repairs, PET, CT and MRI scans, cataract removal, vasectomies and kidney dialysis.

Co-payment cover

There’s cover for co-payments charged for certain surgical procedures, scans and hospital admissions. As an example, Stratum Benefits offers co-payment cover of 15 000 and R40 000 per policy per year on the G-Force and Co-Evolution gap products, respectively.

The co-payment benefit offered by Sirago is subject to the legislated overall annual limit of R150 000 per person per year.

Oncology benefits

The more expensive comprehensive gap cover products offer oncology or cancer benefits. Stratum Benefits has a once-off lump sum cancer diagnosis benefit of between R5 000 and R30 000 on all its products.

The Elite and G-Force options have an oncology benefit subject to the overall annual limit, and an oncology optimiser benefit limited to R100 000 per person per year.

Internal prosthesis benefits

High-end gap cover products, such as Universal Gap Cover by Zestlife, cover the shortfall in the costs of prosthetic hip and knee joints, up to R30 000 per policy per year.

Emergency or trauma cover

Most gap cover providers pay for treatment in the hospital’s casualty or trauma ward, provided the injuries are as a result of an accident or serious illness.

The Sirago benefit varies from R3 000 per policy per year on the entry-level Gap Cover product, to R6 000 on the Ultimate option. Stratum Benefits has causality cover of between R5 000 and R10 000 per policy per year on all its options.

What else?

There’s also typically shortfall cover for in-hospital and/or accidental dentistry, accidental death and permanent disability, trauma counselling and premium waiver.

What gap cover doesn’t cover

In South Africa, gap cover providers only pay for treatments and procedures authorised by your medical aid, and conducted by registered healthcare professionals. Any treatment excluded by your medical aid is not covered.

Although there are exceptions, gap cover does not cover the excess costs of:

  • consultations before and after in-hospital treatment
  • medication and disposable items in and out of hospital
  • crutches and wheelchairs
  • private or home nursing
  • step-down facilities, including frail care
  • depression and other mental health disorders
  • treatment at a non-DSP facility
  • any procedure subjected to a waiting period
  • claims older than six months
  • allied service providers.

How to find the best gap cover

At IFC, we offer informed, objective advice about leading providers of gap cover in South Africa, and can assist you in finding the option that best suits your needs and budget. Contact us for more information or to discuss your needs.