Insurance providers designed gap cover to pay the difference between what experts charge and health schemes pay. But what does gap cover actually cover?
Depending on the policy subscribed to, it can cover the rest of your health bill.
Alternatively, it can pay for daily expenses below your annual upper limit.
This is because occasionally, you will find a bill or two that your primary cover declines to pay or may not be unaware that you do not have comprehensive cover until you make a claim.
What does the product do?
Most people wrongly believe that their health scheme will pay their entire bill in the event of an emergency.
Your medical plan will not provide for your specialist’s procedures, and even when they do, they often put a limit on the amount they cover.
Ordinarily, they set these restrictions as the standard medical rates.
Does it include everything?
When you have yearly upper limits for hospitalisation, you are required to pay for any shortfall that may arise.
The majority of medical consultants charge way more than the standard tariffs set up by health schemes.
Thus, your medical aid will only pay the agreed amount leaving you to pay for the excess.
Medical plans follow pre-established medical rates, but doctors are not obliged to follow the standard rates.
As crazy as it may sound, you health cover will pay 100% of the prescribed tariffs, but the doctor may charge anywhere between 200% and 500% of the standard rates.
Besides, in most of the cases, demand for the medical services dictates the prices, as such the prices fluctuate in either the client’s favour or for the doctors.
That’s where gap cover comes in
Gap plan has nothing to do with your health insurance plan and does not have to play by the same rules.
Thus, you do not have to take your Gap cover with the same company that provides your basic health insurance. But what does gap cover actually cover?
In most cases, Gap tends to be way more affordable than the majority of the medical insurance plans with premiums going for as low as R274 per month.
Besides, considering that the shortfall amount might amount to thousand of Rand, this is not bad. In addition to gap plan covering for a shortfall, they also cater for medical cover shortfalls.
However, dependent on the plan you take, you could also be getting covered for co-payments or deposits relating to hospitalisation, co-payments, as a result of not using the chosen provider and co-payments as a result of costs that exceed your limits.
Does the insurance pay the bills?
Gap cover pays the policyholder directly. You must then use this money to pay the bills. The main disparity between this claim and the one sent to your medical cover is that for this one you have to prove how much the health cover paid out.
We highly recommend Zestlife for medical aid members in South Africa.
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All info was correct at time of publishing