If you have ever travelled on the London Underground, then you will be familiar with the robotic and recorded, ‘Mind the gap’ warning, as train doors open and close. This warning is imperative for your safety.
The same warning applies when you consider your Medical Aid benefits and what you are covered for. Even though you may be paying a seemingly large amount for your Medical Aid benefits, private healthcare practitioners are often charging above the Medical Aid stated tariffs – leaving you to pay the difference from your own pocket. You are responsible for ‘minding the gap.’ This is where South African Gap Cover comes in.
What is Gap Cover?
Essentially, Gap Cover is an extra policy that covers the financial shortfall between what your Medical Aid tariff pays out, and the actual rates charged by private healthcare practitioners for hospitalisation treatments and procedures. If you are 60 years or younger, and already registered with a medical aid scheme in RSA, you are eligible for Gap Cover.
Why do you need it?
Consider this scenario: Your child has had multiple cases of tonsillitis in a year and is now scheduled for a tonsillectomy. Your medical aid has given hospital pre-authorisation and will cover an estimated R1 872 for the procedure. The actual cost of the surgeon and anaesthetist rates and post-operative medicines might come to around R5 222. You would then be responsible to cover the outstanding R3 350. Of course, depending on the procedure, and your Medical Aid scheme, this could escalate to exorbitant amounts. A back fusion could have you forking out a potential R18 000. This is where South African Gap Cover fills the payment gap.
Some Gap Cover policies might even offer further outpatient benefits for procedures such as MRIs, CT scans, chemo, radiotherapy and kidney dialysis.
What else do you need to know?
- If your Medical Aid scheme does not cover stated exclusions, your Gap Cover will not cover these either. Examples of exclusions might include fertility treatments and cosmetic surgeries.
- Some Gap Cover policies might also set a maximum amount for shortfall payouts – which may only end up being a contribution towards the overall difference.
- Waiting periods might also apply – so make sure you check all the fine print and get clarification from the agent before you sign on.
Day1 Health offers a Gap Wise option. Please visit our website to find out more or contact us to request a quote.
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