The cost of living has increased dramatically, and with the ever-increasing inflation rates, this might urge many South Africans to cut down on costs and expenses. The burning question however remains, which expenses stay, and which expenses go? A multitude of people may feel that because they already pay an instalment on medical aid cover every month, there is no need to top-up for gap cover. This could unfortunately end up being a case of false frugality, as you can be liable for heap of rands in additional medical-aid costs. 

What is Gap Cover?

Gap Cover acts as a shock absorber for shortfall costs between your medical aid scheme and the actual rate charged by healthcare providers for in hospital procedures. Gap cover supplements your medical aid. However, Gap cover is not a medical aid and does not replace your medical aid. If you are a medical aid member, gap cover insurers that you and your family are protected if you incur high and unexpected in hospital medical costs. While medical aids are regulated by the medical schemes act, gap cover is short-term insurance which together with your medical aid, provides topup health cover up to certain limits. By nature, its function is to provide additional financial protection to medical aid scheme members who receive in-hospital treatment and care so that they are not dismayed with large out of pocket expenses following a hospital event. Some Hospital and Comprehensive Medical Plans offer cover at 100%, 150% or 200% of medical scheme rates for hospitalisation only, while the actual costs could be up to 500% of medical scheme rates.

Choosing a gap cover benefit

As an additional healthcare benefit, your gap cover should not be regarded in as an independent entity but rather as part of your overall medical risk portfolio. Your medical aid, disability and dread disease cover all play a role in protecting you financially against unforeseeable healthcare costs, so it is crucial to consider all benefits and policies before making your decision. The first step should be to determine exactly what in-hospital benefits are offered by your medical aid and then look for a gap cover policy that compliments this cover by addressing those shortfalls.

Bear in mind, however, that your gap cover is not structured to cover treatment for Prescribed Minimum Benefits (PMB) as these costs must by law be covered by your medical aid. This being said, your medical aid can insist that you use a Designated Service Provider (DSP) when receiving treatment for a PMB, so it is vital to understand your scheme rules. If you choose to be treated in a non-DSP, your scheme may penalise you in the form of a co-payment.

What is covered by gap cover?

Depending on the type of gap cover policy you are subscribed to, there is a wide range of benefits available:
• Out of hospital benefits: In addition to covering up the shortfall for specialist consultations and in-hospital treatment, there is generally funding for certain procedures conducted in the doctor’s rooms and specified in the policy
• Co-payment cover: There is cover for co-payments charged for certain surgical procedures such as scans and hospital admissions.
• Oncology benefits: Premium comprehensive gap cover offer oncology or cancer benefits
• Internal prosthesis benefits: High-end gap cover products cover the shortfall in the cost of prosthetic hip and knee joints
• Emergency or trauma cover: Most gap cover providers pay for treatment in the hospital’s casualty or trauma ward, provided the injuries are as a result of an accident or serious illness.

General Exclusions on gap cover

In South Africa, gap cover providers only pay for treatments and procedures authorised by your medical aid and conducted by registered healthcare professionals. Any treatment excluded by your medical aid is not covered. Although these are exceptions, gap cover does not cover the excess costs of:
• Costs related medical reports
• Stem cell harvesting or treatment
• Costs related to medical reports
• External prosthesis, like artificial limbs.
• Reconstructive cosmetic surgery

Morebo is here to assist you with your specific gap cover needs. Having outlined the benefits and considerations, allow us to help you navigate finding a gap cover plan that will suit and complement your medical aid plan best. With our specialised software, we will be able to generate a meaningful cost and benefit comparison for your needs. This will allow you to make the best decision on what product best suits your requirements.