How Gap Cover Works

Gap Cover is a type of insurance designed to complement your medical aid plan in South Africa. Even with comprehensive medical aid, certain hospital and specialist costs can exceed your plan’s limits, leaving you with out-of-pocket expenses. Gap cover bridges this difference, providing peace of mind and financial protection during unexpected medical events.

What Is Gap Cover?

Gap Cover is an additional insurance policy that covers the shortfall between what your medical aid pays and the actual cost of medical treatment. This is particularly useful in private healthcare, where specialist and hospital fees can exceed your medical aid’s reimbursement limits. By covering the difference, gap cover prevents surprise bills and reduces financial stress.

While your medical aid handles most routine treatments, Gap Cover steps in when:

• Doctors charge more than the medical aid’s rate for procedures.
• Hospital costs exceed plan limits.
• Specialist fees are higher than the medical aid pays.
• Unexpected medical emergencies arise with higher-than-anticipated costs.

How Gap Cover Works

When you have Gap Cover, the process is straightforward:

1. Treatment: You receive medical treatment from a hospital or specialist.
2. Medical Aid Payment: Your medical aid reimburses a portion of the cost based on your plan’s rules and limits.
3. Gap Cover Payment: Your gap cover insurer pays the difference between the medical aid reimbursement and the actual bill, up to the policy limit.
4. Out-of-Pocket Costs: You are only responsible for any remaining amount not covered by either your medical aid or gap cover, though most policies cover up to 100% of the shortfall.

Gap Cover can apply to hospital accounts, specialist consultations, surgeon fees, and in some policies, chronic medication shortfalls. It acts as a financial safety net for those unexpected medical costs that can otherwise strain your budget.

Benefits of Gap Cover

• Financial protection: Covers the difference between your medical aid payment and actual bills.
• Peace of mind: Reduces stress during unexpected hospital stays or specialist visits.
• Flexibility: Many policies allow you to choose the level of cover that suits your needs.
• Emergency coverage: Gap cover can be particularly useful in critical or high-cost procedures.
• Support for shortfalls: Ensures you are not paying large amounts out-of-pocket after an emergency or complex surgery.

Who Should Consider Gap Cover?

Gap Cover is ideal for:

• Medical aid members with limited hospital or specialist benefits.
• Families who want to protect themselves from high unexpected medical bills.
• Individuals planning elective surgeries or private hospital procedures.
• Anyone seeking peace of mind for emergencies and costly medical treatments.

Before purchasing Gap Cover, it’s important to compare policies, check annual limits, and review the list of covered procedures. Some policies also have waiting periods for pre-existing conditions, so early enrollment is beneficial.

Frequently Asked Questions

What is gap cover?

Gap cover is insurance that covers the difference between what your medical aid pays and the actual medical bills for hospital, specialist, or other medical costs.

Do I need gap cover if I have comprehensive medical aid?

Even comprehensive medical aid may not cover all hospital or specialist fees. Gap cover ensures you are protected against high out-of-pocket costs.

Does gap cover pay for routine doctor visits?

No. Gap cover typically only applies to hospital accounts, specialist fees, and unexpected high-cost procedures, not routine doctor visits.

Are there limits on gap cover payouts?

Yes. Most gap cover policies have annual or per-claim limits, which should be reviewed before purchasing.

Can gap cover be used for emergencies?

Yes. Gap cover is particularly useful in emergencies where hospital or specialist costs exceed your medical aid limits.

How do I claim on gap cover?

After your medical aid processes the claim, submit the shortfall account to your gap cover provider. They will cover the difference according to your policy limits.