Medical aid is one of the insurance policies that needs no introduction. Viewed as the most important insurance anyone can get that affects their immediate situation, being covered under medical aid is a sure way of knowing your health is covered. Or is it…
This post was published on 16 May, 2017

Although medical schemes have different options you can choose from, these options vary greatly in their offered benefits. For instance, you can get between 100 – 300% of your hospital costs reimbursed by your medical aid, depending on your policy scheme. Thinking literally, being 100% covered means you do not have to stress about the financial burden of being hospitalized.

However, in South Africa it is common for medical aid schemes to not cover specialists such as an anaesthesiologist or gynaecologist. This means you will need to carry the cost of their services yourself and will not be reimbursed by your medical aid scheme.

This is where Gap cover comes in. Let’s look at what Gap cover is and how it can help you.

What is Gap cover?

Your medical aid will cover your financial expenses up to a certain point. In some cases, the hospitalisation and specialist costs exceed that which your medical aid is willing to support. Gap cover ensures that you won’t feel the impact of these costs by supporting the financial difference. It basically covers all the monetary shortfalls of your current medical aid scheme.

How does it work?

Your current medical aid scheme will reimburse the hospital or specialist directly in the event of your hospitalization while Gap cover will refund you directly. You are then responsible for reimbursing the hospital or specialist yourself.

Is Gap cover connected to my Medical Aid?

Not at all. Your Gap cover is separate from your existing medical aid policy. You’re able to switch between medical aid insurance policies and still have the same Gap cover. Medical aid schemes are regulated by the Medical Aid Schemes and Medical Schemes Act while Gap cover is situated under the Short-term Insurance Act and does not form part of your existing medical aid scheme.

What is the claims process?

Since Gap cover is separate from your medical aid scheme, it does not follow the same rules or procedures as your current medical aid scheme. Your claims process is submitted after the medical aid scheme pays the service providers, including the hospital.

Terms and conditions apply. Please note that the content displayed on this site is for information purposes only and does not replace our policies’ terms and conditions. The policy wording supersedes any marketing material. Any claim will be considered against the terms and conditions that apply at the time of claim and as set out in out customers’ policy documentation.