What is gap cover
Gap cover is a form of short-term insurance that covers potential shortfalls between the cost of medical procedures in hospital and the percentage that your medical aid pays towards these costs. For example, some medical practitioners charge up to 400% of MSR rates. If your medical aid only covers 100% of MSR rates, then a shortfall of 300% will be payable by you. Gap cover will cover this outstanding amount.
How to claim
To claim from gap cover, you’ll need the hospital bill, plus your medical aid’s statement of the shortfall with explanatory codes. The gap cover payout will be paid to you, and you will need to make payment to the hospital or medical practitioner.
Tariff gap: This is the shortfall between the cost of a procedure that your medical aid will cover, and what the hospital charges you. For instance, your medical aid may cover 300% of medical aid rates, but your specialist may charge 400% of medical aid rates. The 100% shortfall is the tariff gap. In the different gap cover options quoted above, the tariff-gap limit is set at 500% of medical aid rates.
Co-payments: Some procedures or hospitals require you to make a co-payment, which is an additional payment for certain procedures that is not covered by the medical aid.
Sub-limit cover: Medical aids may limit the amount of cover you have for a specific event or procedure by putting a sub-limit in place. This means that if you have a procedure too often, or if it costs more than the sub-limit, you will have to pay in yourself. Sub-limit cover will cover the additional procedures over and above your sub-limit or offer you an additional amount above the sub-limit for these in-hospital expenses.
Cancer co-payments or oncology benefit: Some gap covers offer additional benefits for cancer procedures – even if those procedures take place without a hospital admission. For example, certain experimental cancer medication might not be covered by your medical aid, but will be covered by gap cover. Or you will be required to make a co-payment for certain procedures, which the oncology benefit will cover. This is the least clearly defined benefit, and it’s important to read the fine print carefully to understand what benefits you are getting on the plan of your choice.