Medical gap cover is a short term insurance policy that covers medical aid members for shortfalls in payouts. This type of “top up” cover is only available to members on a registered medical aid. Health or medical insurance members are not eligible for gap cover. Although an optional cover, many medical aid members now see it as essential to cover shortfalls in the every rising cost of private healthcare in South Africa. Gap cover will pay anywhere between two to five times (200% to 500%) of the medical aid tariff. This ensures that patients are not out of pocket when their medical aid payout falls short of the doctor’s bill.
How does medical gap cover work?
Gap cover is not unique to medical bills. It is a policy that pays for shortfalls. South Africans are well aware of vehicle gap cover or top up cover. If you car is stolen, you insurer may not pay the full outstanding loan amount. This means that you are responsible for the shortfall owed to your vehicle finance company or bank. With gap cover, the shortfall is instead covered by the insurer. Medical gap cover works in a similar way.
Medical aid is now the main way to afford private healthcare in South Africa. Private hospital care in particular is very expensive. From hospital stays to operating theatre time and surgeon fees, you could be out of pocket for tens of thousands of rands even if you have medical aid cover. Many healthcare service providers, particularly medical specialists and surgeons, charge above the medical aid tariff. This means that the patient is liable for the shortfall between what the medical aid pays and what the doctor charges.
Medical gap cover protects consumers against this shortfall. It will pay for the shortfall after the medical aid has processed the claim. FOr example, your surgeon may charge R30,000 for a procedure while the medical aid tariff is only R18,000. This is where medical gap cover steps in to pay out the remaining R12,000 so that you are not liable for the shortfall. Payment by the gap cover insurer is only made after the medical aid processes the claim but reputable insurers will process and pay out valid claims within 1 to 2 weeks.
How much does gap cover cost?
Medical gap cover usually starts from R180 per month (2020 rates). This will cover only one person on the medical aid and typically the main member. Family cover is approximately R290 per month (2020 rates) and will cover all members on the same medical aid cover. Higher cover can be purchased but will cost more. It is important to understand the policy benefits before choosing the level of cover. The additional benefits on more expensive policies may be well worth the few extra rands.
Most gap cover policies will only pay for in-hospital care. However, there are now some gap cover insurers who will also cover part of the cost for specific out-of-hospital procedures like CT and MRI scans or upper GI endoscopy and colonoscopy. There gap cover policies tend to cost more but the benefits can only be appreciated when you need these expensive diagnostic investigations. Always speak to your gap cover insurer about what level of cover would best suit your budget and your needs.