If you’re on a medical aid plan, you’re covered for any eventuality, right? Wrong!
Most people don’t give their medical aid a second thought, simply trusting that they will be protected when a medical event occurs.
If this was true, then why does Gap Cover exists? What is Gap Cover for that matter and should you be considering it if you already have medical aid in place?
Old Mutual iWYZE explores…
What is Gap Cover?
Gap Cover is in essence medical aid top-up insurance – paying for medical expenses that your medical aid don’t cover.
How does it work?
Your medical aid sets an annual medical aid rate – this is the base rate that can be charged by every medical professional for every procedure.
Most medical aids agree to pay up to a certain percentage of this rate – in most cases up to 300% of this rate. However, medical professionals are free to charge whatever they want for their services, and should your provider charge more, it will be your responsibility to cover the shortfall.
For example: Let’s say your medical aid covers up to 300% of the medical aid rate. If a surgeon charges 400% of medical aid rates, your medical aid will cover the first 300% and you will have to pay the additional 100%.
Medical procedures are expensive, and this can mean an almost instant bill of tens of thousands of Rands, if not more. In short, Gap Cover is additional insurance you buy in conjunction with your medical aid to cover this shortfall.
What does Gap Cover not pay for?
Every Gap Cover policy is different and it’s up to you make sure you understand the fine print and exclusion of your individual policy. This is a list of general exclusions most Gap Cover providers will not pay for:
- Ward costs in a hospital or step-down facility
- Upgrades to a private room
- Pre-admission consultation costs
- Medication (both in-hospital and take-home)
- External prostheses (an artificial breast or a prosthetic leg)
- External appliances, such as wheelchairs or crutches
- Routine medical examinations, such as ultrasounds
- Home or private nursing
- Extra costs related to weight/BMI-related procedures
- Mental health disorders, transportation costs (such as in an ambulance)
- Out-of-hospital dental treatments
- Cosmetic procedures
- Costs incurred for treatment by a non-designated service provider (determined by your medical scheme)
- Co-payments for any procedure for which you are in a waiting period.
It’s important to understand that Gap Cover won’t cover something that your medical aid excludes. It only tops up a shortfall on approved procedures, specialists or medications.
The verdict: is Gap Cover worth it?
Unequivocally, the answer is YES. If you have medical aid, you should have Gap Cover to complement it. Medical procedures are expensive… expensive enough to lead to life-changing debt if you don’t have sufficient protection in place. Gap Cover is a relatively inexpensive way to protect you against potentially crippling debt from medical aid shortfalls.
iWYZE Gap Cover is administered by Xelus (Pty) Ltd, an authorised Financial Services Provider (FSP 36931. Terms and conditions apply.