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Gap cover can be seen as a small bridge which can help you cross muddy waters. In essence, gap cover is an insurance product created to provide the user extra cover if they already have medical aid. It covers the shortfall between a medical scheme tariff and the rates charged by private health care professionals. Subscribing to gap cover will ensure you are protected against financial discrepancies and avoid being required to pay out-of-pocket medical expenses.
Benefits of top-tier gap cover
With top-tier gap cover, up to 500% of the medical scheme’s tariff can contribute to in-hospital and specified outpatient benefits. In addition to these, gap cover may also contribute to co-payments related to hospital admissions, any medical scans and certain surgical procedures. The gap cover you choose to subscribe to may also qualify you for lump sum benefits to cover costs which are associated with certain medical treatments for cancer, accidental dentistry, treatment and care in a casualty ward and internal prostheses. Certain hospital plan insurance require its members to contribute to co-payments, only if they make use of hospitals which aren’t of those in the scheme networks. Gap cover covers up to a certain amount per family per year.
Who is eligible for gap cover?
Any person who is registered with a South African medical aid scheme, who is 60 years of age or younger can qualify for gap cover. The benefits of the cover may extend to the individual’s spouse and dependent children up to a certain age. However, these benefits only cover members of the family who belong to the individual’s medical scheme and has the same medical aid options.
Waiting periods and exclusions of gap cover
Gap cover is no different than conventional medical aids, waiting periods and exclusions do apply. Generally, the waiting period can last for up to three months, including all benefits, notwithstanding a 12-month waiting period for pre-existing conditions. During the course of the wait, neither the medical aid holder nor family are eligible for the benefits of the cover.
General exclusions include cosmetic surgery, specialised dentistry and obesity treatment. It is important to note gap cover providers may decline the cost of co-payments which are stated as percentages instead of amounts in rands. The cover would include any claim older than six months. This also includes a claim with any limit or which has a penalty imposed on it by your medical aid scheme. Gap cover providers may refuse payment to a scheme holder for non-compliance with scheme rules or authorisation procedures.