Why you need to consider Gap Cover

Ever-increasing medical expenses are giving rise to bigger and bigger medical aid shortfalls. That is why you need to know the facts about gap cover.

Medical schemes have a medical scheme rate, which is the maximum amount they will pay for treatment. In many cases, this rate does not align with the rates charged by medical professionals, hospitals nor the cost of medication. Health professionals can charge up to 3 or 4 times the medical scheme rate in some instances, leaving you with significant unplanned medical expenses.

Gap cover helps to cover the shortfall between the rate charged by medical specialists and the rate paid out by a medical scheme. Moreover, gap cover assists with the fees associated with co-payments, sub-limits, and other medical expense shortfalls.

Gap cover is not an alternative to medical aid. It is a complimentary product to cover the difference between medical aid reimbursements of medical costs and the actual costs charged

Technically gap cover is a short-term insurance product, regulated by the Long-term and Short-term Insurance Act 1998 and is completely independent of your medical scheme.  If you change your medical scheme, your gap cover remains in place and vice versa. However, you cannot have gap cover unless you are a member of a medical scheme.

Gap cover often covers more than you realise

We tend to think of gap cover in relation to approved in-hospital specialist claims. However, many of the Gap plans also extend cover to specific out-patient procedures such as MRIs, CT scans, chemo, radiotherapy, and kidney dialysis.

10 month exclusionary waiting period on pregnancy and childbirth

Starting a family should be a period of great joy, but the medical expenses that typically accompany pregnancy, birth, and early childhood can cause a great deal of financial strain. If you are planning to start a family, it is important to note that gap cover providers exclude pregnancy and birth for a 10 month period. This means there could still be a problem, even if you were not pregnant when you signed up, and the baby was born early.

The example below from Stratum Benefits shows the true value of having gap cover. In the illustrated claim for childbirth, the Gap cover policy paid for 68% of the total claim – much more than the medical aid

Even if you are already pregnant, it’s never too late to sign up for Gap Cover

Ideally, you should have medical aid and gap cover in place before starting a family so that waiting periods are not an issue.  However, it’s not too late if you are already pregnant, because although the birth may be excluded, the baby will be covered on the parents’ gap cover policy from the date of birth provided that you inform the product provider within 90 days.

Interested in talking to us about Gap Cover?

Although everyone is trying to tighten the belt on expenses you cannot afford to be left unprotected in areas such as your family’s health care. Before buying gap insurance it’s a good idea to seek professional advice and make sure that it complements your particular medical plan and covers the gaps unique to your scenario for absolute peace of mind.

For more information and expert advice on Gap and Medical Aid products contact us at This email address is being protected from spambots. You need JavaScript enabled to view it. on 021 870 1555 or email This email address is being protected from spambots. You need JavaScript enabled to view it.