Medical Aid Gap Cover Takes Care of Cash Expenses for Hospital Stays

More and more people are considering medical aid gap cover over and above medical insurance. The National Health Reference price list or NHRPL governs the amounts that aid schemes pay. Albeit, it cannot dictate to hospitals and doctors, who in most cases quote prices higher than those on this list for any given procedure.

Why Gap Cover?

This difference in price creates a need for medical aid gap cover. Most privately run facilities including hospitals, clinics, and rooms for specialised care often charge up to 300% more than what the NHRPL ha set out as the price.

Thus, members of aid schemes find that they are not covered for health costs they thought they would never have to worry about. Indeed, they have to pay these gaps out of their own pocket. Further, the cover is usually up to a limit of five times the NHRPL rate.

medical aid gap cover

This rate is often below healthcare providers’ rates, leaving patients with a heavy financial risk exposure. For the sake of illustration let’s say, you go into hospital for a procedure and the specialist sends a bill of R 15,000.00. The medical insurer pays the hospital/ specialist R 10,000.00.  Medical aid gap cover then covers the R5000 gap left here. For some people, R5000 is not a lot of money. But it’s still huge sum when they have to suddenly pay it when they expected to be fully covered. Some schemes pay up to 300% the NHRPL rate. But even then, gap cover is vital as experts may charge up to five times more than the NHRPL rate.

Who can get Medical Aid Gap Cover and for How Much?

Gap cover is the insurance product that has come into this market to bridge this discrepancy. Anyone who is already on medical aid can take this cover; it is not available to people who have no health insurance cover.

Let’s take Zestlife as an example. Enhanced Universal Gap Cover benefits in 2019 include:

  • Overall regulatory maximum for medical expense shortfall cover increased from R150 000 to R160 000.
  • Cancer lump sum increased from R25 000 to R30 000.
  • Casualty benefit increased from R10 000 to R20 000. Casualty visit must be within 48 hours of the accident.
  • Medical Aid and Gap Cover Premium Waiver maximum increased from R6 500 toR7 300.
  • Medical Aid and Gap Cover Premium Waiver limited to accidental only, but the payment period increased from 3 to 12 months. This change was due to legal requirements.
  • Accidental dentistry maximum increased from R15 750 to R19 250 and amount per tooth increased from R2 250 to R2 750.
  • Non-Designated Service Provider co-payment increased from R8 600 to R9 300.
  • Oncology co-payment maximum increased from 20% to 25%.
  • Cover for robotic procedures up to R30 000.
  • Cover for procedures in day clinics.
  • New Oncology Benefit to cover 20% of treatment cost when oncology limit is exceeded.
  • Varicose veins have been added as an out-of-hospital procedure that is covered.

Zestlife Premiums 2021:

Gap cover providers differ with regards to waiting periods. Some have none while others apply a waiting period of three months before considering a claim.

Members over 60 years of age can also expect to pay some excess on some benefits with some insurers.

Any broker would recommend gap cover as an add-on to primary health schemes. Regardless of the rate of reimbursement from the primary health insurer.

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All info was correct at time of publishing