Why is Medical Gap Cover Controversial?

It may shock you to learn that despite the steep premium, your medical aid might not cover all your expenses. That is true when it comes to hospital treatments. Gap cover should cover the shortfall. But why is medical gap cover controversial?


What is Medical Gap Cover?

The South African government has drawn up the National Health Reference Price List. The idea behind the list is to give a guideline for reasonable and fair healthcare costs.

Why is Medical Gap Cover Controversial

The medical aids make a decision at the beginning of the year as to what they will pay out for medical procedures. That accords with the government’s list, an analysis of claims paid to date and the premiums they will have.

Sounds good so far, doesn’t it?



Why is Medical Gap Cover Controversial?

In theory, it seems like a good idea. In practice, the medical practitioners have no legal obligation to charge either of the rates.

That could leave you in a bit of a sticky situation. Let’s say that the medical aid rate for a procedure is R20 000. Depending on your plan, they will pay R20 000 for that operation. (In some cases, they do pay double or triple the laid down rate.)

Now, the doctor, anaesthetist, hospital, etc. may charge what they want to. That could mean that the procedure costs R40 000. You will need to find the R20 000 yourself or face debt collection procedures.

Gap cover is there to pay that. Gap cover is controversial because of government’s promise to address the issue of the gap. Proposed regulations will see the full cover for a range of Prescribed Medical Benefits. The regulation of health provider’s charges may also be considered.


Moving Away from the Medical Aids

Because of this shortfall, in particular, many South Africans are becoming disillusioned with their medical aids. Some feel that it would be simpler to choose a hospital plan instead of a medical aid.

And, if there were no gap cover, they probably would.


How Industry Leaders View Proposed Regulations

Discovery Health is of the opinion that gap cover should be scrapped. According to them, government intervention would wipe out the need for health insurance and gap cover products for the most part.

They believe that this would benefit all concerned.


The Financial Services Industry

They differ from Discovery and believe that gap cover is something that should not be cut. The financial services industry believes that doing so will damage this multi-million Rand industry. They are of the opinion that government needs to address the following instead:


The Insurance Industry

That is where the issue is most hotly contested. Brokers and the providers of the cover have come out overwhelmingly in favour of it. Those promoting medical aids seem to be opposed to it.


The Council for Medical Schemes

The Council voiced its concerns about the non-regulation of gap cover. They believe that gap cover as it now undermines the medical schemes.

They believe that there is a role to be played by health insurance but that they need to complement and not compete with medical schemes.

Why is medical gap cover controversial? It could be because it works. If you belong to a medical aid, get a quote now


All info was correct at time of publishing