GAP COVER
What is Medical Aid Gap Cover?
Gap Cover provides cover for the medical shortfalls that could occur when the medical service provider charges more than what the medical scheme tariff for hospital procedures are. These shortfalls would be for the medical scheme members own account. Another benefit is CoPay Cover, a benefit for the co-payments which medical schemes can impose on certain in- and out-of-hospital procedures.
Gap Cover is a product underwritten by Western National Insurance Company Limited.
Who can apply for Gap Cover?
Gap Cover is available to any member of a medical scheme that is registered at the Council for Medical Schemes in South Africa. There is no age limit.
What does Gap Cover cost?
Option 1: Gap Cover Only: R150 per family, per month
Option 2: CoPay Cover Only: R70 per family, per month (limited to R10 000 per event)
Option 3: Combined Cover – Gap Cover & CoPay Cover: R200 per family, per month
Why Gap Cover?
In most cases, members have a shortfall between what the medical scheme pays and the actual cost, because the Service Providers are entitled to charge more than the medical scheme tariff. The shortfall then becomes the member’s responsibility and could leave him/her out of pocket.
Some Hospital and Comprehensive Medical Plans do offer cover at 100%, 150% or 200% of the medical scheme tariff, while the actual costs could be more than 500% of that set tariff.
The medical schemes are also allowed to impose co-payments on certain in- and out-of-hospital procedures, also an expense for the members’ own pocket.
Gap Cover offers cover for the difference between what your medical scheme will pay and the actual cost of in-hospital doctor’s bills up to a maximum of 500% more than medical scheme tariff. CoPay Cover could cover the medical scheme co-payments on specified procedures.
Waiting Period
- Maternity benefits will only accrue after a 12-month waiting period.
- 12-month general waiting period on pre-existing conditions.
Please Note
The total benefit per gap policy is R150 000 per beneficiary, per annum.
Members must confirm the benefits covered, exclusions and the rules of the specific medical scheme, as Gap Cover cannot cover shortfalls within overall annual hospital limits or co-payment on certain procedures, as stated by the medical scheme rules.
Should your scheme have an annual hospitalisation limit, Gap Cover will not be liable to pay the difference between what your scheme covers and the cost of the account.
Example:
If the medical aid scheme specifies that it will cover R10 000 for a prostheses, the member undergoes a knee operation and the prostheses costs R25000, Gap Cover will not be liable to pay the difference.
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