By: Michael Emery
Gap cover is a range of products to cover medical scheme members for the shortfall (Gap) resulting from specific medical practitioner charges above the medical aid tariff. Despite growing adoption, many people still have misconceptions about what gap cover does – and doesn’t – cover.
Here are some of the top questions brokers are asked:
Is gap cover an alternative to medical aid?
Gap cover is an insurance product, not a medical scheme, and the cover is not the same as that of a medical scheme. Gap cover is only available to members of a medical scheme, to limit the out-of-pocket medical expenses not covered in full by the medical scheme. It is not a substitute for a medical scheme. The products are generally designed to cover major medical events in hospitals and specific outpatient treatments and procedures.
Does the gap cover overcome the self-payment gap?
It’s a common misconception and important to note that gap cover has nothing to do with the self-payment gap. Gap cover is only applicable for in-hospital treatment or procedures and certain specified outpatient procedures. Medical aid savings and self-payment accounts are intended for use to pay for day-to-day medical expenses. When the savings are depleted, the member becomes personally liable for further expenses.
Does gap cover apply to co-payments?
Co-payments – typically from service providers and specialists charging above medical scheme rates – are among the top gap cover claims.
Co-payment is also required where medical scheme rules designate that a specific portion of certain procedures are paid personally by the member, or where a member reached the coverage limit set by the medical scheme for oncology. Medical scheme rules also permit schemes to levy penalties for certain kinds of behaviour – such as failing to obtain pre-authorisation – and are often referred to as penalty co-payments.
Depending on the terms and benefits of the policy, gap cover can be used to defray some or all of these co-payments. However, gap cover generally does not cover shortfalls owing on medicines.
What doesn’t gap cover pay for?
Typically, gap cover is not designed to pay for medication and fees strictly related to hospitalisation such as bed, food, or bandages. It won’t cover any procedure not covered or declined by the Medical Scheme, or Prescribed Minimum Benefits which should be provided for by the Medical Scheme in full.
Gap cover exclusions typically include obesity, cosmetic surgery, suicide, alcohol and drug abuse and addiction, treatments and investigations relating to artificial insemination or hormone treatment for infertility, as well as routine procedures that are purely diagnostic and that are objectively not related to health impairment.
What are the gap cover waiting periods?
Normal exclusion periods when an individual takes out gap cover: a general 3-month waiting period and a 12-month pre-existing condition waiting period. However, claims as a result of an accident are covered from the inception of the policy.
Can I cover extended family?
Depending on the gap cover provider, cover can be obtained for dependent parents, adult children, and grandchildren, although generally adult dependents would need their gap cover policy in place. Grandchildren will be covered only if they have been legally adopted or fostered. Different gap cover providers have different definitions for a family, so it is important to check how the family is defined in your gap cover policy.
To learn more, consult a financial advisor who can assess your needs and risks, and advise you on a gap cover product to suit you and your family.
* Emery is a marketing executive at Ambledown Financial Services.
PERSONAL FINANCE