Gap Cover covers the shortfalls between what your Medical Scheme will pay and the rates charged by in hospital Medical specialists.
In SA, medical schemes have different options from which you can choose, and these options vary in the benefits offered, and of course also the cost of the contributions. When choosing a medical aid option, you will see that professional services (such as the surgeon or anesthetist) in hospital will be reimbursed at either 100%, 200% or 300% of the scheme rate. Now anyone will be forgiven for assuming that being covered at 100% means exactly that – you are fully covered! However, specialists in South Africa are not regulated as to what they can charge patients for their services, and could charge in excess of the 100% rate which medical schemes are willing to pay – sometimes as much as 500% of the scheme rate! The end result – the patient ends up with a short-fall on the specialist’s account, which he has to pay out of his pocket.
HOW DOES GAP COVER WORK?
Gap cover does not form part of your medical scheme membership – in fact, it is not even regulated by the same laws. While your medical scheme is regulated by the Council for Medical Schemes, and the Medical Schemes Act, Gap cover falls under the Short-term Insurance Act.
While your medical aid will reimburse the hospital or specialist directly when you are hospitalised, because of the regulatory issues, your Gap cover provider will refund you, the member, directly. It is then your responsibility to reimburse the service provider.
The process of claiming is also separate from your medical scheme. Usually, a Gap cover claim must be submitted after your medical scheme has paid the service provider. Having a Gap policy is also not dependent on a specific medical scheme. You can change medical schemes, but still keep the same Gap cover.