Medical Gap Cover Shortfall Solutions

When it comes to planning for medical emergencies, most South Africans just join a medical scheme and leave it at that. What most of us do not understand is that being a member of a medical scheme is no longer enough. You need medical gap cover shortfall insurance too.


No Recourse Against the Medical Aids

Many have found that out the hard way when the medical aid pays only a portion of their bills. And there is nothing much you can do about it after the fact – the medical aid acts in accordance with the small print in the policy.

When joining a medical scheme do not overlook the terms “medical aid rates” or “medical aid tariffs”. The industry sets the rates and these are the basis upon which medical aids settle claims.

They may pay 100% or 200% of these predetermined tariffs. This would be great if the health care

Medical Gap Cover Shortfall Solutions

providers charged the same rate but they seldom do.

The health care providers can charge a premium for the services that they offer and they normally do. This could mean that they charge far in excess of the medical aid rates.

You could end up having to pay at least as much as your medical aid does. In some instances, you could end up having to pay any more.


What is Medical Gap Cover Shortfall Insurance?

Medical gap cover comes into play once your medical aid has paid their portion of the bill. The gap cover will pay the remainder, in accordance with your policy.

This is not a medical aid but rather a type of insurance product. Not all medical aids may sell insurance products as well so you may need to look for an insurance company such as Talksure or Sirago.

The pre-requisite for all gap cover plans is that you are currently a member of an official South African medical scheme.


What Do These Plans Cover?

This differs from plan to plan but generally speaking, you will have hospital cover. However, you might need to ask for pre-authorization if the procedure is not a medical emergency.

  • In-hospital benefits will normally include doctor’s fees, specialist fees, some radiology fees and pathology fees.
  • Cover may extend to deposits that have to be paid on admission to hospital.
  • Most policies will have some prescribed minimum benefit cover.
  • Most will include a lump sum payment for death, dread disease diagnosis or disability.
  • No cover for elective cosmetic surgery.
  • No cover for elective cosmetic dentistry may also not be covered.
  • Certain outpatient treatments may be covered – such as chemotherapy or dialysis.
  • Waiting periods are usually standard with these policies.
  • You will normally not be covered for expenses relating to pre-existing conditions or pregnancy during your first year.


How Much Can I Expect to Pay?

Again, this depends on who you take the policy out with and the level of cover that you select. Expect to pay around about R300 a month for relatively basic cover.

The premium does usually also cover dependents listed on your medical aid as well.

Considering the cover you get, these policies are not that expensive at all. And they may just save you from financial ruin.

Get your medical gap cover shortfall quote. Just complete and submit the form on this page

All info was correct at time of publishing