Medical Gap Cover is a Necessity for Medical Aid Members

With the exorbitant cost of healthcare in South Africa, it is no surprise that most people cannot afford private care without medical aid. At one time South African consumers could rest assured that their medical aid cover will pay for all medical bills for essential services. However, this has been rapidly changing over the past few years. There days medical aid payouts will only cover part of the bills and members can find themselves out of pocket for thousands or even tens of thousands of rands in doctors’ bills.

Fortunately this shortfall that has been hitting consumers hard in their pockets has been catered for with gap cover. It is a separate cover from medical aid and pays for what medical aid does not. Medical aid gap cover pays the shortfall between what the medical aid pays and what the doctor charges for in-hospital services. This can be up to 500% of the medical aid tariff although new laws may soon reduce this to a maximum of 200% cover.

Is Medical Aid Gap Cover Choice or Necessity?

The fact of the matter is that you are not required to have gap cover if you have medical aid. Similarly medical aid is not mandatory, not even for employers to provide to their employees. Medical aid is a choice to ensure that you can afford costly private healthcare services when you fall ill. However, if you are still facing exorbitant bills after your medical aid pays out then it may seem short-sighted not to have medical gap cover as well which is relatively inexpensive

Consider a scenario where you use your medical aid’s hospital maternity benefits only for giving birth in a private hospital with private specialists. The hospital itself usually charges medical aid rates. Your obstetrician may charge R12,000 for a C-section delivery and the anaesthetist charges R6,000 for the procedure. However, the medical aid tariffs only pay the gynaecologist/obstetrician R4,000 while the anaesthetist is covered up to R2,000. Ultimately there is a R12,000 shortfall – R8,000 for your obstetrician and R4,000 for the anaesthetist.

Without medical aid gap cover, you will be personally liable for this R12,000 shortfall. That is a R12,000 payment that you have to make even after your medical aid reimburses the practitioners. While this may not seem like a substantial amount of money, the same scenario can play out for any other hospital procedure. Consider that the total cost of a coronary artery bypass surgery for a heart attack can run up to R400,000.

It Just Makes Sense

At this point, medical gap cover becomes more of a necessity for medical aid members than a matter of choice. However, if you have the cash resources to fund these shortfalls out of your own pocket then you can still opt not to have gap cover. Remember that gap cover costs as little as R300 per month for an entire family. When you consider this cost in comparison to the bills you may be liable for, the choice for gap cover is obvious.

Who Qualifies for Medical Gap Cover?

Medical gap cover is available to any medical aid member. Consumers who have hospital cash plans (hospital insurance) or health/medical insurance plans do not qualify for gap cover, just as people who are not on medical aid or any other type of cover. There is also no age restriction for joining gap cover just as there there is no age limit for medical aid. However, it is important to be aware of the waiting periods that can affect claims and payouts.

Waiting Periods for Gap Cover

There are two waiting periods that are applicable to gap cover. Firstly there is a 12 month waiting period for all claims, except childbirth. In these 12 months, some gap cover insurers will not pay for any claims for the first 6 months and then up to 50% in the second 6 months. Once the 12 month period has lapsed, then the gap cover is fully active and will pay for legitimate medical claims.

The second waiting period applies to childbirth. This is a 10 month waiting period. It means that there is no benefits available for the first 10 months from the time of inception of the policy. As is the case with medical aid for pre-existing pregnancy, this maternity waiting period ensures that women do not only sign up for cover when they need it and then quit the cover after giving birth.

Individual gap cover insurers may have other clauses in place for exclusions. For example, cosmetic procedures are not covered by gap cover in the same way that medical aid will not pay for it. Remember that gap cover usually only pays for hospital-related procedures. Day-to-day medical expenses, or out-of-hospital care, are not covered. However, some outpatient procedures may fall within the ambit of gap cover depending on the insurer.

What if my medical aid does not pay?

This is common question from medical aid members who discover that their medical aid will not pay for certain hospital expenses. The fact is that your gap cover only pays the shortfall after your medical aid has paid. If your medical aid is not paying for a procedure, then your gap cover will also not pay for it. Although gap cover functions separately from medical aid cover, the same exclusions and waiting periods apply.

Therefore if your medical aid has a valid reason to not pay for a claim then the same reasons will apply to gap cover payouts. In other words – no medical aid payout, no gap cover payout. In these cases you will be liable for the entire medical bill out of your own pocket. It is therefore important to speak to your gap cover insurer prior to a procedure in the same way as you would get authorisation from your medical aid for a procedure.

Despite these restrictions, gap cover can be a financial lifesaver for any medical aid member. Without the resources to pay for shortfalls in medical bills, consumers may find themselves heavily indebted and even blacklisted in the long run. Medical gap cover is inexpensive and can prevent these inconveniences in life.