Why do you need medical gap cover for your family?

Having medical aid is the best thing you can do for both you and your family. How will you cope if your medical aid doesn’t cover all medical expenses for hospitalisation or a specialist?

This is where medical gap cover can come to your rescue.

In this blog, Auto & General shows how gap cover works, what it covers and doesn’t cover, and how it differs from medical aid. If you’d like to learn more about these things, read on.

What is gap cover?

Consider this scenario: On a certain Sunday in 2020, a 25-year-old man was playing soccer. When trying to prevent a cross, an opponent collided with his right knee, knocking it to the side. Sadly, the game was over for this young man.

He was taken to a private hospital and the orthopaedic surgeon diagnosed him with a torn knee ligament. The only way to fix it was to perform an operation. Fortunately, our young man had comprehensive medical aid. The operation went ahead and succeeded.

Within days, our young man received a letter from an anaesthetist who wanted him to pay an extra R2,100. The medical aid hadn’t covered all the expenses that this medical professional charged for her role in the operation. Unfortunately, our young man didn’t have other means to pay this fee except from his own pocket. Had he had medical aid gap cover, his insurer would have covered that cost.

A situation like this can happen to anyone, whether playing sports or doing do-it-yourself (DIY) projects at home. It’s a savvy financial decision to consider having medical gap cover.

Gap cover is short-term insurance that covers excess costs that medical professionals charge over and above medical aid rates. This insurance is necessary considering that healthcare professionals are allowed to charge up to five types more than medical aid plan rates.

With medical gap cover — which you can think of as medical aid top-up — you won’t have to worry about this. Your shortfalls will be covered without you spending a cent from your pocket. This means gap cover protects you financially, which helps if you are working toward goals that need money like vacations or investing in your children’s education.

What is covered and what are the benefits?

When you have gap cover, you need to know what it covers and what it doesn’t cover. Let’s first discover what’s included in it. By design, this insurance covers in-hospital procedures and treatments and some out-of-hospital treatments and procedures.

The specifics of gap cover also depend on the type of cover you’ve taken and the ages of those covered. Auto & General has medical gap cover plans for individuals and families younger than 65 and for those aged 65 and above.

There are three types of cover: 

• Essential Gap Cover — a basic cover

• Comprehensive Gap Cover — a standard mid-range cover

• Absolute Gap Cover — the ultimate cover

For instance, for in-hospital procedure shortfalls, Essential Gap Cover covers up to 300% of the medical plan rates while Comprehensive and Absolute Gap Covers pay up to 500% and 700% of the medical plan tariffs, respectively.

Medical gap cover generally covers the following and more:

●      In-hospital specialist shortfalls

●      Prescribed minimum benefits (PMBs)

●      Emergency treatment in the casualty unit

●      In-network hospital co-payments

●      Out-of-network hospital co-payments

●      Sub-limit benefit: Internal Prostheses

●      Sub-limit benefit: MRI/CT/PET Scans

●      Dental treatment shortfalls

●      Oncology

●      Global fees

●      Out-of-hospital benefits

There is no single answer to the question “What does Medical Gap Cover safeguard you against in South Africa?”  To know what actual benefits you qualify for, it’s best to check your policy.

Medical aid vs gap cover: What's the difference?

The first thing to understand is that you can only get gap cover if you have medical aid, although you can have medical aid without gap cover. This means that before you consider applying for gap cover, you must first have medical aid.

The second element of importance is what is different between medical aid and gap cover. Here are the main differences.

●  The premium for medical aid ensures you’re covered for qualifying medical expenses whereas that of gap cover protects you financially against shortfalls.

●  A medical aid fully covers expenses on all conditions included in the list of prescribed medical benefits (PMBs) as stipulated by the Medical Schemes Act 131 of 1998. These costs vary based on the medical aid scheme provider and the type of medical aid plan you have. Gap cover covers shortfalls incurred for medical expenses to treat conditions excluded in the list of PMBs.

●    With the recent significant rise in medical inflation, medical aid schemes came under pressure to provide the same benefits. However, this effect didn’t impact medical gap cover.

The big thing to realise is that medical aid alone may not provide maximum health protection. It’s far better to combine it with gap cover to ensure you’re financially covered for most treatments and procedures.

What isn’t covered by medical gap cover in South Africa?

Now that you know what’s covered by a medical gap cover, it’s time to look at what it doesn’t cover.

Medical aids exclude certain health treatments and procedures. Since gap cover tops up expenses paid by medical aids, it follows that conditions not covered by medical aids don’t get covered by gap cover.

The other aspect to consider when looking at what gap cover includes is the type of plan you have. In the three Auto & General gap cover plans mentioned earlier, there are differences in the level of cover that each provides. 

●    Cover for emergency treatment and procedures in casualty: Essential Gap Cover pays up to R7,500 annually per policy, while Comprehensive and Absolute Gap Covers will pay up to R15,000 and R20,000 per policy each year, respectively.

●  Oncology extender benefit: This element comes into play once you’ve exhausted your medical aid scheme’s oncology limit. It’s  not available for both Essential and Comprehensive Gap Covers but pays an aggregate amount per insured individual per year in the case of Absolute Gap Cover.

●  Out-of-network hospital co-payments: The first two gap cover plans don’t cover this, however, the Absolute Gap Cover pays up to two co-payments for up to a combined total of R15,000 per policy annually.

There are other differences between the three types of gap cover plans. Your specific inclusions and exclusions are covered in your policy.

Common medical gap cover terms explained

There are common gap cover terms you should be aware of, including

●     Accident: It’s an unintentional, unforeseen and sudden instance that results in anything from damage and loss to injury and death.

●  Benefit: Medical procedures, treatments and medicines you'll receive. This varies based on the type of gap cover you choose.

●     Waiting period: A period within which a gap cover policy doesn’t protect you. Although there is a general three-month waiting period, some conditions may dictate waiting ten months before qualifying for cover.

●  PMBs: It’s short for prescribed minimum benefits, a list of health conditions that medical aids are obliged to cover in full, including emergencies.

●  DSP: It’s short for a designated service provider, a medical professional who a medical scheme considers a preferred supplier.

●  Tariff gap: The shortfall between the cost of a procedure that a medical aid will cover, and what the hospital charges.

●  Enhanced cancer cover & oncology benefit: Cover for cancer procedures such as chemotherapy and specialised radiology that a member receives as additional benefits whether in or out of hospital.

●  Sub-limit benefit: A ceiling that a medical scheme imposes to limit the amount of coverage for specific procedures. If it happens that you need to undergo a procedure too often or if it exceeds the sub-limit, you will have to pay for it yourself. This is where medical gap cover comes in; it will cover any additional procedures or provide an additional amount above the sub-limit.

There are many more terms you’ll find in your policy, and it’s important to understand them in order to make the most of your cover.

Get Medical Gap Cover from Auto and General

Medical aid schemes don’t always fully pay for medical treatments and procedures. The shortfall could be many thousands of rands, which is why having gap cover is the sensible way to go.

If having gap cover sounds like a good move to you, Auto & General can be of help. Simply request an online gap cover quote. If anything is unclear, rest assured that a trained consultant will be happy to answer your questions.