Age is always a concern when it comes to insurance products and this is no different for medical gap cover. Your medical aid cannot impose an age limit. You can join a medical aid at any age, although late joiner penalties apply for members older than 35 years. Similarly you can stay on medical aid cover throughout your life, irrespective of age. This does not apply to other healthcare products like medical insurance (which is not medical aid) or medical gap cover.
Maximum Entry Age on Gap Cover
Previously, there was a maximum entry age of 65 years on medical gap cover policies in South Africa. This means that if you could not get medical gap cover protection if you were older than 65 years. However, gap cover insurers have realised how this adversely affects many medical aid members. It is unfair to senior medical aid members who often need medical gap cover protection to a greater extent than youger members. Now many gap cover insurers have no maximum entry age. This means any medical aid member of any age can join gap cover.
However, it is important to note that senior gap cover plans are often more expensive. Seniors tend to require more medical care than younger adults and children. It is just a reality of ageing. This means that insurers will face more claims, and often more expensive claims, from senior members. Therefore the risk is priced into the gap cover premiums and senior members will pay significantly more for medical gap cover products whether it is part of a family plan or standalone individual plan for a senior.
Age-Related Exclusions for Senior Gap Cover
It is important to understand how gap cover works and how it differs from your medical aid cover. Firstly your medical aid cover and medical gap cover are two different products. Some medical schemes are now offering in-house gap cover plans but these are still short term insurance policies that are technically separate from your medical aid cover. Your medical aid cannot exclude conditions based on your age although there may be waiting periods that apply after signing up for medical aid cover.
Gap cover on the hand can apply exclusions as the insurer chooses. This means that medical gap cover is not blanket cover that will pay for all shortfalls that arise with medical aid. Your medical aid may pay for all conditions but your gap cover may not pay for shortfalls on all conditions. However, your gap cover insurer has to stipulate at the outset as to which conditions will be excluded from the policy cover. Often these are conditions which you have or had and where there is a high chance of recurrence.
Naturally age plays a part in this equation. As you get older, you are at greater risk of certain conditions which may be part of your family history or past medical history. In fact just about any condition is more likely to occur in your senior years than it is to occur earlier in life. Some of the exclusions on gap cover may appear to target older members but this is not always the case. Overall the protection offered by gap cover, even with exclusions, far outweighs the risk of medical aid shortfalls which you have to pay from your own pocket.
Medical aid is expensive. If you joined a medical aid late in life then the additional late joiner penalty (LJP) may substantially increase your monthly contributions. You may be wondering if you really need medical gap cover but as a senior there are distinct advantages of this additional cover. It will complement your medical aid cover and afford you better private healthcare which is often not affordable on a cash basis.
There are many reasons to justify gap cover as a senior medical aid member. For example, the risk of a heart attack increases with age. Consider that coronary bypass surgery for heart attack treatment or prevention can cost R750,000 and that the most cardiothoracic surgeons charge above medical aid tariffs. You could be left out of pocket for tens of thousands of rands for the medical aid shortfall if you do not have gap cover.