Do I need GAP cover to go with my medical aid?

We often find clients contacting us asking to take out GAP cover because of advertising or because they have heard from a friend or colleague that their medical aid left them with some bills to pay when they went into hospital for a procedure. They are scared that they might end up in the same situation.

On investigation we have discovered in nearly all cases that either the GAP cover would not have helped or that the shortfall was avoidable.

We recommend that before you take out GAP cover to discuss with us if it is really necessary based on which medical aid and option you are on an assessment of the risk of having any financial shortfalls if you go into hospital.

What is GAP cover?

GAP cover is a short term insurance product. It is not medical aid.

So what does GAP cover provide in general? 

A lot of clients assume that GAP cover will cover any financial shortfall in hospital and sometimes out of hospital. This is not true. Each policy has a defined list of benefits and maximum payments.

Each provider provides very similar base benefits and then may have some individual additional benefits. There is usually an annual limit on total benefits of say R150,000.

The similar benefits are

  • In hospital Specialist cover
    • For emergency hospitalisation the medical aid normally pays your bills at the cost charged. So usually GAP cover would only help you for planned procedures. If you have a planned hospital procedure, e.g. having a baby, hip replacement etc. and the specialists charge more than the medical aid rate then the GAP cover will pay up to an additional 200% of the medical scheme rate. This does not automatically mean that all of a shortfall will be paid.
  • Co-Payment Benefit
    • This is designed to cover any of the co-payments on certain procedures, mainly CAT,MRI,PET and certain specialist referral procedures
  • Oncology extender benefit
    • Most medical aids have an oncology benefit that covers at 100% up to a limit of say R200,000 per anum then has a co-payment of 20% for amounts above this. The oncology benefit is designed to cover this shortfall up to a maximum amount of say R100,000

Possible additional benefits may include

  • Hospital admission extender benefit – limit say R20,000
  • Premium protector – Pays your medical aid for 2 years in the event of a severe illness etc
  • Home Support benefit – max say R10,000 per anum
  • Medical procedures outside of hospital shortfall – e.g. gynaecological, neurology, cardiothoracic surgery
  • Internal Prosthesis shortfall(R30,000 max),casualty benefit R10,000 max),lump sum cancer diagnosis benefit(R15,000) ,accidental death and disability benefit (R50,000)

How much does GAP cover cost?

The cost may depend on the plan you are on, your age and if you take a basic plan or one with additional benefits, the cost can range from say R96 to R665pm for a single member and from R159 to R1250pm for a family.

In conclusion, if you think you may need GAP cover please call us to discuss and ascertain if it is really necessary.

This article is a general information sheet and should not be used or relied on as professional advice. No liability can be accepted for any errors or omissions nor for any loss or damage arising from reliance upon any information herein. Always contact your financial adviser for specific and detailed advice. Errors and omissions excepted. (E&OE)