Complete guide to Medical Gap Cover Insurance in 2024

A medical gap cover in South Africa is a short-term insurance policy that covers the excess costs that a medical aid doesn’t cover. In South Africa, a medical gap cover starts at R199.00 per month and can cost thousands of rands for those that require a higher cover amount. An insurer can pay between 5% and 100% of medical aid shortfalls with a medical gap policy.

A medical gap cover has its own limitations in that it does not always cover the entire excess fee that a medical aid does not cover. As a result, a medical gap insurance policy allows policyholders to select the amount of gap cover for a hospital stay.

Medical gap insurance became increasingly popular in South Africa at the beginning of the last decade. Specialist doctors can charge 500% or more than what your medical insurance aid covers. As a result, many people are opting for medical gap cover to finance the additional fees that specialist doctors charge.

A medical gap policy provides numerous benefits to the policyholder. The following are some of the benefits of having Medical Gap Cover.

Medical Gap Cover Benefits

• A medical gap insurance policy pays for expenses that a medical aid does not cover. There is a disparity between the tariffs of the medical scheme and the actual rates charged by medical professionals.
• The principal insured can tailor their medical gap insurance to the amount of coverage they require. (Some companies impose a maximum coverage amount for medical gap insurance.)
• The principal insured and other listed beneficiaries can benefit from medical gap coverage.
• Medical gap cover premiums are low.
• Certain medical gap policies provide lump sum benefits to cover the costs of critical illness treatment.
• Medical gap coverage can include both in-hospital and out-of-hospital benefits.
• Specialised benefits such as an increased pay out in the event of hospitalisation due to violent crime.

Medical gap cover provides numerous benefits; however, it also has limitations. The limitations of medical gap coverage are discussed below.

Medical Gap Cover limitations

A medical gap policy has some limitations that you should be aware of as these limitations may affect your your benefits. The following are the most common limitations associated with medical gap cover.

1. Maximum annual limit

A medical gap cover comes with an annual limit and t his is the maximum amount cover amount per year, and it cannot increase. The total annual limit for a medical gap cover in 2023 is R178,000.00.

 Policyholders must be aware of the maximum annual limit on their medical gap insurance. Remember that a specialist doctor can charge far more than your medical insurance, in some cases by over 200% of your medical gap cover.

As a result, one may have to pay for some or all of their medical bills.

2. Changes in your medical scheme cover

Medical scheme plans can change over time and these changes can affect your gap cover. Your medical gap cover will only cover what your medical scheme covers. So if your medical scheme changes this will affect your benefits.

Should your medical scheme change, you need to reconsider, whether it still makes sense for you to keep your gap cover. Otherwise, you will get a shock of your life when you want your medical gap cover to pay what your previous medical scheme was covering you.

3. Waiting period

A medical gap cover comes with a waiting period for new policyholders. This is because of pre-existing medical conditions as gap cover providers will want to pay attention to your health.

Before taking a gap cover you need to know the waiting period of your cover. Especially those who suffer from a chronic disease as this might save you a fortune in hospital bills.

What to consider when taking a medical gap cover

Since you now understand the limitations of medical gap insurance, it is time to look at the considerations you must make when purchasing gap insurance. 

Here are some things to think about before or after purchasing gap insurance.

1. Be sure your medical shortfalls will be covered

Be 100% that your medical shortfalls will be covered. You need to seek assurance through your financial advisor that medical shortfalls will be covered owing to the overall annual limit.

2. What happens when you change or downgrade your medical plan

Changes to your medical scheme can affect your medical gap cover. You will need to find out what it entails should you downgrade or upgrade your medical scheme. This will prepare you should you want to take any cause with your medical scheme plan.

3. Whether your gap cover compliments medical scheme

Since the gap cover only covers what your medical scheme covers, you need to be aware of your medical scheme benefits. When you are aware of what your medical scheme covers you can then take a gap cover to suit your needs. Otherwise, you might not even need a gap cover at all if your medical scheme only covers what you deem as less important medical procedures or those that are inexpensive.

4. Understanding limits on your medical gap cover

Know your annual limits on your gap cover and make sure that it makes sense for you. You can do necessary calculations keeping in mind the standard specialist rates and also your medical scheme benefits.

5. Protection of your overall annual limit

Your cover provider should do the right thing by making sure that your annual limit is protected. There are a number of things that your gap cover provider can do, these may include:

• Negotiating discounts on your medical bill.
• Do investigations on whether or not should the claims be covered by the medical scheme.

Conclusion

Medical gap cover is more important than you might think in terms of covering medical bills. This is especially true for those who have a medical plan with a high number of dependents. Your spouse and children can benefit from gap insurance, which will save you money.

A major benefit is that gap cover usually has no age restrictions and can accommodate anyone regardless of age, however, most companies only provide medical gap cover to those under 60 years of age.