As a general rule, medical gap cover will not pay the shortfall incurred for any treatment that is not covered by your medical aid. Both fertility treatments and plastic surgery are usually not covered by your medical scheme. Therefore gap cover benefits will not apply. However, if there is some underlying factor that has contribute to infertility and needs to be treated, then gap cover benefits could apply in the event that your medical aid does not pay the full bill. A similar situation could apply to reconstructive surgery. However, this has to be clarified on a case-by-case basis with your gap cover provider.

Fertility Treatments vs Causes of Infertility

Medical aids only cover essential procedures unless there are certain mitigating circumstances that may apply to non-essential procedures. Fertility treatments are not considered as essential despite the psychological impact it can have on adults. It is therefore not covered by most medical schemes although some restricted medical aids did previously include benefits for its members. However, the same may not always apply to the causes of infertility.

For example, polycystic ovarian syndrome (PCOS) and endometriosis are two fairly common causes of infertility in women. It may require medical and even surgical treatment if the symptoms impact a person or if it holds the risk of further complications. Therefore medical schemes usually cover for both medication and surgery related to these conditions. Therefore your gap cover provider may also provide benefits for shortfalls that arise with medical aid.

Treating these conditions may increase fertility which can allow a woman to fall pregnant. However, when it comes to specific fertility treatments like in vitro fertilisation (IVF), medical schemes generally do not cover this costly procedures. Therefore gap cover benefits will not apply for IVF and related fertility treatments. However, gap cover for pregnancy will still apply irrespective of the conception methods. This is only related to the medical aid cover for pregnancy although gap cover insurers usually do not pay for prenatal care on an outpatient basis.

Plastic Surgery – Cosmetic or Reconstructive

Plastic surgery is a broad term that is applied to several types of surgery. Most of us associate plastic surgery with cosmetic surgery, which is only one type of plastic surgery. Usually cosmetic surgery is not covered by medical aids and will therefore not be covered by gap cover insurers. However, the benefits may apply differently to reconstructive surgery. In the event that a medical scheme will cover reconstructive surgery then the gap cover benefits may extend to any related shortfalls.

There are some situations where plastic surgery may not be considered essential yet your medical scheme could cover it. It is usually applied to situations where there may be an ongoing psychological trauma if the surgery is not conducted. The medical aid benefits may not always be sufficient for the plastic surgery in question and members with gap cover will depend on this extra policy to pay for the shortfalls that arise in these situations.

However, it is important to note that medical gap cover is not a blanket shortfall policy. This means that it will not always cover medical aid shortfalls. There may be exclusions. Although in-hospital procedures usually fall within the ambit of gap cover, there are specific treatments or procedures that may be excluded and are usually stipulated by the gap cover insurer. It is therefore essential that medical aid members who have gap cover clear every procedure with their gap cover provider before undergoing a procedure.