Video: How medical gap cover works

If you have recently been hospitalised or undergone a medical procedure, you may have been faced with a bill from your doctor which was not fully covered by your medical scheme. In some cases there may be a co-payment for an elective procedure, or the specialist charged more than the medical scheme is prepared to pay.

If you don’t want to be caught by surprise the next time you are hospitalised, you should consider gap cover. This is an insurance that meets the shortfall between your medical bill and the payment made by your medical scheme.

Like any insurance, the more comprehensive it is, the more you pay for it. Gap cover ranges from as low as R120 per month for a family, up to R300 per month, so you need to know what is included. Some only cover for a shortfall between the doctor and the medical scheme while others include the co-payment on elective procedures. A more comprehensive cover will include a visit to the emergency room as well as additional benefits for oncology and prosthetics.

What you need to be aware of is that gap cover only pays for specialist bills in-hospital and doesn’t cover a visit to a specialist.

Also, be aware that this is an insurance not a medical scheme so they impose waiting periods and exclusions for a period of time. They can also exclude specific conditions. An example would be a pregnancy which would be excluded for 10-12 months from inception of a policy.

Gap cover can only be provided to individuals who are members of medical schemes at it pays the gap between the medical bills and what has been paid by the scheme. For individuals who are not members of a medical scheme but want some type of health insurance, there are other products such as hospital cash plans and primary healthcare plans.

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