Gap cover for medical aid explained

Often, the amount that your chosen medical scheme is willing to pay for a medical procedure will be less than what the specialist charges – especially if you’re using a provider who doesn’t belong to your medical scheme’s network.

In this case, YOU will have to pay for this shortfall (or co-payment) between your medical scheme’s tariff (MST) and what the provider charges. Medical aid gap cover is short-term insurance cover that is completely separate from medical aid, and covers a portion of the co-payment that you’re responsible for.

Gap cover is designed for people who already belong to a medical aid, so you can’t take out a policy without having pre-existing medical aid cover. There are many different gap cover providers in South Africa, all of whom provide different levels of cover. Some of them may cover hospital admissions, surgical procedures and medical scans, as well as outpatient expenses for up 500% of the MST. Others have cheaper premiums, but offer a lower reimbursement percentage, and for fewer medical expenses.

The criteria for applying for medical aid gap cover are that you must be younger than 60 years, and already belong to a medical scheme. Similar to medical aid, there’s usually a waiting period for joining gap cover and receiving all the benefits. There’s also a year’s waiting period for pre-existing conditions, during which time you won’t be able to claim.

Even if you have medical aid, you could be faced with huge medical bills to pay over and above what your medical aid will cover. In these instances, gap cover could help alleviate the financial strain – especially for large medical expenses in the case of a serious illness or accident.

Choosing the right medical aid is no joke, but we’ll leave you smiling.