FAQ

Medical Gap Cover

  • What is Medical Gap Cover

    The Medical Gap policy covers you for medical practitioner expenses incurred in hospital, that your medical aid may not pay. This policy provides your family up to depending on the a  cover amount per annum to fill the gap that may result between the actual practitioner cost and the medical scheme tariff.

    The Medical Gap cover benefit is calculated as the difference between what the medical practitioner charges (up to a maximum of 5 times the Admed Tariffs) and the medical scheme tariffs. In order to claim a benefit, your practitioner account must be more than the medical scheme tariff.

  • Advantages:

    • GAP Cover should be viewed as indispensible to any insured belonging to a Medical Scheme.
    • This product covers all major shortfalls with regards to in-hospital admissions, which includes Registered Medical Professional fees, Co-payments, Admission fees, Penalty Fees, Out-patient Surgical Procedures that would normally be performed as an in-patient, Emergency Room Cover and cover for when you are unable to use the Designated Service Provider prescribed by your Medical Scheme rules.
    • The product can be added to any Medical Scheme. The principal member and his/her Spouse can even belong to different Medical Schemes.
    • There is no maximum entry age.
    • Covers in-hospital Dentistry and Optometry
    • Covers the anaesthetist, gynaecologist, radiologist, pathologist and other Registered Medical Professionals
    • The product is extremely affordable and will cover a family of 5 members (2 Adults and 3 Children).
    • Child dependent up to the age of 21 and can be extended to the age of 27 in respect of full time students (documented proof is required)
    • A stated benefit is paid straight into your bank account
  • Who should buy Medical Gap Cover

    If you are a medical aid member and if you are concerned about having to fund costly treatment for you and your family that may not be fully covered as a member of a medical aid you should buy Medical Gap Cover.

  • What is the benefit of having Medical Gap Cover

    Most in-hospital procedures requiring treatment by a surgeon, anaesthetist and/or a radiologist could leave you (the medical aid member) with a payment shortfall.

    This happens because medical scheme benefits are limited to the medical schemes tariff applicable to the option chosen, whereas medical practitioners have been known to charge up to four times the medical scheme tariff. This creates a shortfall between the medical scheme tariff and the actual charge by the medical practitioner for the treatment, for which you would be personally liable.

  • Can I Afford to be without Gap Cover?

  • The National Health Reference Price List  (NHRPL) is a pricing system maintained by the Department of Health and the Council for Medical Schemes. The NHRPL specifies the rates to which your medical aid scheme must adhere. It is the amount of money that they are bound by law to pay out for a given situation. Doctors, hospitals and other medical service providers however, are not bound to these rates, and in fact charge up to 300% above these NHRPL prices. So despite thinking you are financially covered for any medical eventuality in its entirety, for the most part you are not, and are often liable for an enormous shortfall.
  • Some Hospital and Comprehensive Medical Plans offer cover at 100%, 150% or 200% of medical scheme rates for hospitalisation only, while the actual costs could be more than 500% of medical scheme rates. Gap Cover  will cover the difference between what your medical scheme will pay and the actual cost of in-hospital doctor’s bills up to a maximum of 500% of medical scheme rates. Listed below are four common medical procedures, with the combined charges of the specialist, anaesthetist and surgeon. The third column illustrates the payment shortfalls an individual on a standard, 100% of MSR, scheme option would experience.

    Can I use Gap Cover with any medical scheme?

    Yes, this specific gap cover policy can be used in conjunction with any medical scheme registered in South Africa.

    Why is a policy waiting period of minimum 12 months imposed on  pre-existing conditions?

    With  Gap Cover there is a waiting period imposed. This is because of the high level of anti-selection.  These procedures and/or operations are covered  after the waiting period has expired

    What is a PMB?

    Prescribed Minimum Benefits (PMB) are a set of defined benefits to ensure all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable.

    PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of:

    • any emergency medical condition;
    • a limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs);
    • and 25 chronic conditions (defined in the Chronic Diseases List). There is often a shortfall between what a medical scheme pays and the actual cost of a procedure or treatment, because service providers are entitled to charge more than the medical scheme rate. The shortfall then becomes the member’s responsibility and he/she will therefore need to have additional cover under these circumstances.

    When will the first premium payments be debited?

    The first premium will be debited within the first month of cover – see the Application form for debit order dates available.

    Will the Gap Cover premium be debited together with the medical scheme contribution?

    No, Gap Cover  is a separate insurance product administrated by a different company.

    Why would I need this product?

    Combined Cover is a product that should be viewed as a comprehensive product, necessary for any insured belonging to a Medical Scheme. All major shortfalls with regards to in-hospital admissions, which includes Registered Medical Professional fees, Co-payments, Admission fees, Penalty Fees, Out-patient Surgical Procedures that would normally be performed as an in-patient, Emergency Room Cover and cover for when you are unable to use the Designated Service Provider prescribed by your Medical Scheme rules.

    What if my Medical Scheme doesn’t pay for a procedure?

    We will not compensate you for any illness, condition, disease or injury, or the consequences of treatment of, or resulting from, or associated with any claims or claim portions not authorised or paid by the your Medical Scheme.

    What is the cancellation period?

    There is a 30 day cancellation period before any debits are stopped on your account.

    Are there any waiting periods?

    There is a 3 month general waiting period and a minimum of 12 months on pre-existing conditions.

    What will happen to my  Cover product if I change Medical Schemes?

    No changes will be made to your  Cover product, our only requirement will be the notification of such a change.

    How long do I have to submit a claim?

    You will have 90 days after the payment date of your Medical Scheme to the service provider. We shall not be liable for claims submitted outside of this timeframe.

     

     

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