Complementary cover for medical expenses almost as important as good medical aid


You need supplementary cover for your medical expenses, even if you and your family are affiliated with a good medical aid scheme.

Unexpected shortfalls in your medical coverage when you have a medical emergency or even for a planned medical procedure can leave you with a hefty bill that will destroy your budget.

Gap coverage is a short-term insurance policy that covers the difference between the costs paid by your medical plan and actual medical costs for defined inpatient and outpatient treatment, says Michael Emery, marketing manager at Ambledown Financial Services.

“Many people discover too late that, while their medical aid will cover 100%, 200% or even up to 300% of their tariff for hospital treatment and procedures, the actual costs of the procedures could be much higher.

“As comprehensive as your medical aid is, there is a good chance that not all of your costs will be covered, which will result in a loss of income that you or your family will have to pay. Patients without gap coverage often end up with a large specialist bill after a serious illness and a long hospital stay,” he says.

If your bill from your specialist is, for example, R10,000 and your medical aide pays R3,000, you will have to pay the shortfall of R7,000. If you have gap cover, you can submit a claim for the remaining R7,000.

“Medical aid schemes often only cover costs according to their rates, while many healthcare providers and specialists charge more than the medical aid scheme rate. This hedging gap can amount to tens of thousands of rand.

ALSO READ: Looking for a medical aid scheme? Here’s how to choose the best one for your needs

Gap cover designed to cover gaps

Gap coverage is designed to minimize deficits, covering up to 600% of medical expenses, minus the medical plan reimbursement rate and many gap coverage products also cover certain co-pays and imposed sub-limits by medical assistance schemes, says Emery.

You can use gap coverage to help pay for major medical hospitalization co-payments and the shortfall of what is owed after your medical assistance coverage for hospitalization or certain procedures. It may also offer cancer coverage and dreaded disease benefits.

However, says Emery, it’s important to remember that gap coverage is not a medical plan. The cover is not the same as that offered by a medical aid scheme and therefore does not replace membership in the medical scheme.

This coverage is only available to members of the Medical Plan and is designed to cover inpatient treatments and procedures and certain defined outpatient treatments and procedures, such as chemotherapy and radiation therapy for the treatment of cancer, as well as certain endoscopes and scanners .

“These policies are not designed to cover shortfalls and daily expenses that arise after your medical savings account has been depleted and gap coverage will not cover any procedures not covered or denied by your medical assistance plan .”

However, says Emery, it is not possible for a gap cover provider to calculate in advance what the costs of a treatment will be and what the patient will be responsible for, because the cover will only be calculated once once all bills have been submitted to your doctor. aid scheme and the scheme has determined its liability.

Once a claim is submitted, a claims assessment is conducted and payment is made to the Primary Member. For specialists, gap coverage will only cover up to a maximum of its coverage limits. Most gap coverage providers cover 600% of the medical plan rate, minus the amount paid by medical aid.

ALSO READ: Prescribed Minimum Benefit Medical Coverage: What Is It And How To Use It?

How much does it cost?

Premiums for gap cover can start from R180 per month to cover you and your family. As benefits increase, premiums also increase. Emery says that to determine which product best suits your needs, you should contact your broker.

He points out that gap coverage providers generally charge a higher premium if you join later in life when you’re over 65. Gap insurance policies also typically include a 12 month waiting period for any pre-existing conditions.

Because gap coverage is a short-term insurance product, premiums are not tax deductible, but benefits, on the other hand, are not taxable.


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