Health Planning


Chat to most people who’ve had a hospital stay (or scan HelloPeter) and you’ll hear complaints of hefty co-payments or of medical aid schemes not paying the bills. It’s bad enough that healthcare costs are going through the roof, without the added burden of   having to worry about the effects on your pocket of unforeseen medical expenses not covered by medical aid plans. Gap cover is becoming more important for peace of mind.

You’ve probably heard of “gap cover”, but may not know exactly what it is, and how it would help if you already have medical aid. Medical gap cover generally covers  in the event of emergency surgical procedures not fully covered by ordinary medical aid cover. However, the benefits of gap cover show up not just in a medical emergency; it also covers more expensive day-to-day health-checks that require additional payments. If you don’t want to find yourself writing out an IOU to your medical aid scheme, you need to know your medical benefits and limitations. Whether you need dentistry or  specialised medical treatment, that’s really when gap cover can save the day.

Medical aid schemes are increasingly subscribing to the practice of covering members with minimum healthcare benefits only, depending on the tier of medical aid. The better your medical aid cover, the more benefits you’re likely to have, but this is also reflected in premiums. It’s important to know exactly your medical aid policy covers. There is, for example, a big difference between a hospital plan and standard medical aid which dictates items for which you can claim. You may assume your medical aid will cover 100% of the costs associated with any medical procedure you may require in the event of illness or accident. This is where knowing the finer details of the plan you’re on, prepares you for unplanned medical problems and circumstances. Anything that does not form part of your potential basic medical needs is less likely to be covered in full by your medical aid plan. Medical schemes seldom cover cosmetic surgeries, and there are some conditions that may require related procedures, leaving you financially vulnerable. Specialists often charge more than medical aid rates for their services. When you are referred to one, you should check what your medical aid would cover, and any financial shortfall you may face.

If you have a family history of, or have been diagnosed with, a serious medical condition which will require a specialist, then speak to your medical aid consultant immediately to prepare for any shortfall. Again, you may perceive that 100% cover means total specialist medical cover, but it often does not. Anesthetists and specialists are likely to charge in excess of the 100% cover for which your medical aid makes allowances. A surplus charge of up to 400% of your medical aid benefits is possible, and you would be liable for the deficit.

Dental cover also has potential shortfalls. This has much to do with the way in which the costs of different dental procedures may vary, and again the tier of medical aid to which you have subscribed. Consider your dental needs and those of any dependants on your cover. Ask your dentist what possible complications could arise that may not be covered by your current medical aid.

With the rise of gap cover in the short-term insurance market and health insurance options available, you may be considering downgrading or opting for a less expensive medical scheme cover. Remember, though, that gap cover should act as a supplement to, and not a replacement for, your traditional health insurance.

Standard comprehensive health cover is still the most essential form of medical financial protection, a necessity, not a luxury. It’s best to survey options first before making decisions about medical plans and gap cover, and to compare medical aid and gap cover quotes.

Gap cover is a relatively new entrant into the insurance market, and few people understand its potential to alleviate unforeseen financial burdens associated with surplus charges for specific specialist procedures. Having started as cover that mainly dealt with the shortfall of specialist fees, gap insurance has since moved towards providing cover for sub-limits and co-payments once medical aids started restricting their benefits. Given the current climate and the current lack of regulation around specialists’ fees in particular, gap cover has become an integral part of the developing healthcare industry and will continue to provide this cover so long as its cost does not make the overall product cost too expensive for the market.

Some Tips in selecting Gap Cover:

  • Find a good advisor. Few people are aware of the additional benefits available.
  • Choose an option which matches with your medical aid plan’s benefits. If a procedure is excluded on the medical aid, even if it’s a listed benefit in the gap policy, you can’t submit a claim. Generally, your medical aid should make a payment in order for you to have a gap cover claim. Always read the fine print on waiting periods.
  • Understand your medical aid option/plan properly: know where shortfalls lie. Then see which gap cover option best fills those ‘holes’.
  • Look for 500%/five times medical aid rate cover. Co-payment is a key benefit. Read and understand benefits and conditions. The scheme to which gap cover attaches can be complex – consult an expert for advice.
  • You need not disclose that you have gap cover.

Not only is it an essential element when it comes to financial planning and helping individuals and families alike avoid the pressure of unforeseen medical expenses, it also has a flexible component. Gap insurance providers offer a range of gap cover products and is considered a portable product in that if you want to change to a new medical aid, you can do so with your gap product. You also have the freedom to make sure that your gap product benefits are aligned to your new medical aid benefits, and if necessary, you can change your gap cover to one that is better suited to your needs.

The truth is that the current climate of medical aid providers means that it is no longer enough to have a medical aid plan. More often than not, you discover that your medical aid has only covered a portion of your overall cost after a stay in hospital, leaving significant shortfalls to pay that you hadn’t budgeted for. This is precisely why gap cover has become a vital product and less of an add-on.

For optimum benefits and cover in healthcare, and peace of mind, Contact Us to set up an appointment.