Understanding Gap Cover in South Africa: Everything You Need to Know

What is Gap Cover and Why is it Important?

Gap Cover in South Africa is a short-term insurance product offering additional in-hospital coverage to those with medical aid. It aims to bridge the “gap” between what your medical aid covers at Medical Scheme Rates (MSRs) and the prices charged by private healthcare professionals. 

This disparity often arises due to higher fees charged by specialists or private hospitals. Gap Cover is only available to those with medical aid and not Health Insurance. Refer to this article differentiating the two: Understanding the difference between Health Insurance and Medical Aid.

Curemed Advisors recommend Gap Cover as a necessary supplementary product to medical aid, due to the inevitability of shortfalls for in-hospital expenses. Whilst medical aid providers are non-profit organisations, overseen by the Council of Medical Schemes (CMS), private healthcare costs commonly exceed MSRs due to the lack of standardisation amongst private practitioners. Recognising Gap Cover’s role in minimising hospitalisation shortfalls, highlights its importance when seeking comprehensive healthcare coverage. 

Our Medical Aid Advisors provide guidance throughout the complexities of medical aid selection. We help identify potential shortfalls in medical aid plans and offer solutions such as Gap Cover to avoid excessive out-of-pocket expenses whilst ensuring individuals receive optimal medical coverage tailored to their needs and budget. 

How Does Gap Cover Work?

Explaining Medical Scheme Rates

Medical Aid providers operate according to MSRs which are predetermined amounts that medical schemes contribute towards specific healthcare treatments and procedures. These amounts are stipulated by your medical aid provider according to your specific plan. Medical schemes commonly provide coverage for 100% or 200% of MSRs. A few premium plans offer 300% of MSRs. 

This means that if your in-hospital bill reflects a certain amount, your medical aid will pay 100% of the MSR (or as stated in your plan) towards that amount. However, in-hospital and specialist fees often exceed the MSR benchmark due to a lack of standardisation in the pricing of private healthcare. Consequently, in-hospital shortfalls occur and the member is responsible for the outstanding balance. 

When do medical shortfalls occur? 

Shortfalls occur as a result of the disparity between MSRs and the fees charged by independent healthcare providers. In-hospital expenses are sometimes double, triple or five times more than the standard MSR. Without Gap Cover, individuals face financial strain in trying to keep up with these hefty out-of-pocket, hospital expenses.

CALCULATE YOUR SHORTFALL TODAY

Role of Gap Cover in Covering Shortfalls

Gap Cover is crucial in minimising the financial burden of hospitalisation fees. By offering supplementary insurance coverage, Gap Cover bridges the gap between MSRs and expensive in-hospital bills. With Gap cover, individuals protect themselves from unexpected costs, minimising potential financial burdens whilst receiving critical in-hospital care.

Understanding Gap Cover in South Africa

Client Examples of Gap Cover 

Nicolene 

5 stars (26 April 2024)

This was one of the best experiences ever. No paperwork. Drs got paid promptly. 

Great service.

Francois 

3 stars (4 Jan 2024)

Claim Process Nightmare

Not happy at all. Firstly my claim was just rejected at face value as “Not Accident Related” where the person who was working with the claim could have just taken the time to send me an email or make a phone call to inquire.

Secondly the amount that was eventually paid out was less than the claim submitted. 

As a Absolute+ customer I’m very disappointed in how my claim was handled and the hoops I have to jump through in order to get the claim processed.

Dee

1 star (6 Dec 2023)

Waste of time only for claim to be rejected instead of being upfront

Absolutely disappointing to say the least. After weeks of getting documents for my gap cover claim, it was rejected instead of saying that I was still in the 3 month waiting period. Makes me feel more ill. Seems I should have waited 3 months to get my breathing issues procedure for gap cover to assist. Wish I had a choice on which gap cover to use. This entire process has made me feel more sick and stressed than not being able to breathe properly. Not recommended.

Benefits of Gap Cover in South Africa

Financial Protection Against Medical Expenses

Gap Cover offers financial security from unforeseen in-hospital bills, providing access to essential healthcare services without the concern of additional expenses. Gap Cover offers reassurance by covering a wide range of in-hospital expenses, enabling you to effectively manage your healthcare costs with peace of mind. 

Gap Cover is a vital safeguard against unforeseen medical facility fees. By briding the gap between MSRs and actual charges, Gap Cover shields individuals from financial strain due to unexpected hospital bills. Choosing Gap Cover enhances financial security by ensuring individuals are not left vulnerable to unexpected in-hospital costs. 

Access to in-hospital specialists

With Gap Cover, you have access to specialist care and treatments that may otherwise be financially out of reach, ensuring you receive the best in-hospital care. Whether you need to consult with a specialist for a specific condition or require specialised treatments such as chemotherapy or dialysis, Gap Cover can help cover the associated costs, enabling you to access the care you need without delay.

It is important to understand the extent of in-hospital services covered by your medical aid. This enables you to identify potential gaps in private healthcare coverage. This is valuable in recognising areas where Gap Cover offers assistance with specific in-hospital services. 

When can I use Gap Cover? 

  • In-hospital shortfalls 
  • Qualifying out-of-pocket expenses 
  • In-hospital specialist fees 

Peace of Mind for Families

For families, Gap Cover provides invaluable peace of mind, knowing that their loved ones can receive comprehensive in-hospital care without facing exorbitant out-of-pocket expenses. By offering additional financial protection, Gap Cover allows families to focus on what truly matters – their health and well-being – without the added stress of financial uncertainty.

Who Should Consider Getting Gap Cover?

Gap Cover is highly recommended for various groups in South Africa, especially:

Individuals with Medical Aid Plans 

Individuals with medical aid plans are prime candidates for Gap Cover. While medical aids provide essential coverage, they often fall short of covering the full extent of in-hospital expenses as they adhere to MSRs. Gap Cover acts as a crucial supplement, ensuring comprehensive protection against unforeseen hospitalisation fees. 

Families with Dependents

Families with dependents, such as children or elderly relatives, can greatly benefit from Gap Cover. With additional members to consider, the likelihood of encountering medical expenses increases. Gap Cover offers peace of mind by covering the gaps left by standard medical aid plans, ensuring that the entire family receives the hospital care they need without financial strain.

Comprehensive Health Coverage

Individuals seeking comprehensive health coverage should consider Gap Cover. Whether you’re concerned about potential shortfalls in your medical aid plan or simply wish to enhance your overall coverage, Gap Cover provides an extra layer of financial protection, allowing you to access quality in-hospital services without worrying about the associated costs.

How to Choose the Right Gap Cover Plan

Assessing Your Current Medical Aid Plan

Start by evaluating your current medical aid plan to identify any potential gaps in coverage. Consider factors such as benefit limits, exclusions, and co-payments to determine where additional protection may be needed. If you’ve been diagnosed with an illness, consider your treatment plan and steps required to maintain your health. 

Comparing Gap Cover Providers

Allow Curemed to assist with researching and comparing Gap Cover providers to select a plan that is best suited to your needs and budget. As independent Advisors, we work with a variety of reputable providers who are reliable, transparent, and offer excellent customer service.

Understanding Policy Limitations and Exclusions

With Curemed’s guidance, review the terms and conditions of each Gap Cover policy to understand any limitations or exclusions that may apply. We know that medical jargon is confusing which is why we’re here to help with reading between the lines. Similarly to your medical aid plan, identify coverage limits, waiting periods, and specific conditions that may not be covered, ensuring that you select a plan that aligns with your specific needs and expectations.

Medical aid vs Gap Cover 

Using a comparison table to differentiate between Medical Aid and Gap Cover

AspectMedical Aid Gap Cover
Coverage According to your particular medical aid plan Provides additional in-hospital cover
CostMonthly premiums Monthly premiums (typically lower than medical aid as it is a supplementary product)
Limits and exclusions Specific benefit limits (as listed in your plan)Offering in-hospital coverage (varies according to each plan)
Access to specialistsCovers a portion of specialist and in-hospital fees in relation to MSRs Covers potential shortfalls of hospitalisation fees, plan dependant

Steps to Get Gap Cover in South Africa

Researching Gap Cover Providers

Contact Curemed today to advise on the best Gap Covers for your needs and your medical aid. It is crucial to consider factors such as coverage options, premiums, and customer reviews to narrow down your choices. Once again, look at what treatments you and your loved ones need and compare this to what your current medical aid covers. Reflect on the inevitable becoming a reality and what’s essential for maintaining both your health and financial well being. 

Applying for Gap Cover

Curemed Advisors create comparative quotes suited to your pocket and medical requirements. Once you have decided on a Gap Cover, our expert Advisors are #alwaysthereforyou throughout  the application process. It is important to provide the details of your current medical aid as well as an accurate description of your medical history. 

Reviewing and Understanding Policy Terms and Conditions

Before finalising your Gap Cover, carefully review and understand the policy terms and conditions. Pay close attention to coverage limits, waiting periods, exclusions, and any additional benefits offered by the plan. Ensure that you fully understand what is and isn’t covered under your Gap Cover policy to avoid any potential shortfalls and disappointments. 

Frequently Asked Questions About Gap Cover

What Does Gap Cover Typically Exclude?

Similarly to medical aid, Gap Cover has a few exclusions including: 

  • If your medical aid hasn’t paid a portion of your medical expenses.
  • Gap Cover doesn’t cover upfront fees that need to be paid privately. 
  • Not all Gap Covers offer coverage for mental health issues and incidents involving drugs or alcohol unless they fall under your Prescribed Minimum Benefits (PMBs)

Can I Get Gap Cover if I Have a Pre-Existing Condition?

Yes you can. However, waiting periods and exclusions can still apply. 

Is Gap Cover Affordable?

Gap Cover is typically cheaper than medical aid as it is an additional supplement to your healthcare plan. Gap Cover is affordable and offers protection from hefty medical bills. Gap Cover is worth adding to your medical care as a means to protect your financial stability when receiving in-hospital medical care.

Conclusion: Securing Your Health and Finances with Gap Cover

Gap Cover plays a crucial role in securing your health by providing financial stability. It bridges the difference between coverage offered by medical aids in relation to MSRs, and the high costs of in-hospital fees. Given the inevitable shortfalls between these, Gap Cover serves as a safety net for unexpected medical expenses. Curemed Advisors encompass a holistic approach to your health, wealth and financial well-being. Offering comprehensive guidance with essential aspects of your life ensures a healthy and financially stable future for both you and your loved ones. 

At Curemed we emphasise the importance of Gap Cover because being unable to afford your medical bills affects both your health and quality of life. Let the Curemed Advisors assist with selecting the right Gap Cover tailored to your needs and budget, enhancing your overall healthcare experience. 

Disclaimer: Terms and Conditions apply. This blogpost and the information contained within it is intended for information and consumption purposes only and does not by any means supersede the Rules of the Scheme. In the event of any discrepancy between this mailer and the Rules of the Scheme, the Rules of the Scheme will prevail.

Related articles:

8 of the best Medical Aids to join in South Africa.

Discovery Health vs BestMed: A complete review of plan types, benefits and savings

Momentum Health vs Discovery Health

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