Get Cover After Reading This Gap Cover Guide

Here we have a short and sweet gap cover guide for those new to Gap cover.

  • Always read about a product before buying
  • Educating yourself can save you money
  • Regard Gap Cover as a top-up policy
  • Gap Cover can save you from bankruptcy
  • Understand what does and doesn’t have coverage


What is the Gap Cover Guide?

Gap Cover GuideThis article will give you a better understanding about Medical Gap Cover, an optional extra add-on type of insurance that will cover you for the difference between your medical aid payouts and the final costs imposed by members of the medical profession.

The majority of medical aid schemes do not fully cover medical bills and in fact, some will only pay one-third of what it will cost you to undergo a hospital procedure.

Just think about that for a minute.

An operation costing R150,000 could leave you with a shortfall of R100,000. This category of a shortfall could bankrupt the ordinary man-in-the-street!

And that is why Gap Cover is crucial. Yes, it may cost you extra insurance premium payments every month but it could also end up saving you and your family from financial disaster.


How are Gap Cover payments assessed?

The cost of gap cover depends on several factors which include:

  • The age of the oldest member/dependent
  • Whether you opt for a Family or Individual policy
  • The categories of protection and/or shortfalls you select


The different Cap Cover categories – Gap Cover Guide

You can select one or more of the following categories:

  • Gap Cover Benefit. This provides up to an additional 500% cover when in-hospital procedures cost more than your medical aid is prepared to pay
  • Co-Payment Benefit. This will reimburse you for out-of-pocket expenses when your medical aid imposes co-payments and/or deductibles. Medical schemes usually impose co-payments and/or deductibles for hospital admissions, MRIs and CT scans and endoscopies
  • Sub Limits Benefit. In general, medical aid schemes impose a limit on the amount they will pay for specified medical procedures such as operations and internal prosthesis.
  • Oncology Benefit. Cancer treatments are subject to payment limits and medical schemes will often also impose a co-payment if the cost of treatment exceeds your annual treatment allocation.


Age-related Gap Cover costs for 65 years and older

If you or a dependant are 65 years or older, your Gap Cover payment options are as follows:

Compact 200 package. Cost: R370 a month

  • This package covers you for specialised in-hospital treatment of 200% above the medical aid rate but you remain responsible for any shortfall amounts
  • Co-payment Cover of up to R15,000 per policy annually
  • Sublimate Cover pays up to R15,000 per event, limited to R30,000 annually

Oncology Cover – Gap Cover Guide

Oncology Benefits when co-payments are applied for your continued cancer treatment:

Co-Evolution package. Cost: R420 a month

Gap Benefit of up to an additional 500% for specialised in-hospital treatment

Co-payment cover limits to R50,000 annually

Waiting Periods – Gap Cover Guide

From the date of joining there is a three-month waiting period before you can submit a claim

This waiting period excludes claims for injuries sustained in accidents

So there is a 12 month waiting period for pre-existing medical conditions

Pre-diagnosed Cancer Waiting Periods

Gap Cover is only payable to policyholders who were pre-diagnosed with cancer before taking out the cover after a minimum period of three consecutive years in remission after the start of the cover.

When will claims not be paid? – Gap Cover Guide

There are a number of scenarios under which claims will not be paid but, most importantly, these include:

  • When the policyholder fails to request pre-authorisation from his/her medical aid scheme (such as using a non-network hospital)
  • Also, when a member fails to follow the rules of the medical aid scheme
  • Maxillo-facial surgery and related medical conditions/procedures (unless necessitated by an accident)
  • Dental implants, orthodontic, prosthodontic or cosmetic dentistry
  • External prostheses, artificial limbs, wheelchairs and crutches
  • Robotic surgery
  • Artificial insemination, infertility treatment or contraceptives (excluding tubal ligation)
  • Vasectomies
  • Obesity
  • Cosmetic surgery
  • Breast reconstruction (as a second or subsequent reconstruction)
  • Home nursing or admission to a step-down facility
  • Mental illness or stress-related conditions
  • Attempted suicide
  • Drugs or alcohol
  • High-risk professions such as the military and police force


If you are a member of a medical aid, complete and submit the form on this page to get a Gap Cover quote.

All info was correct at time of publishing