Gap Cover
Gap cover pays the difference between what your medical scheme pays a specialist and what that specialist charges. It is a short-term insurance policy rather than a second medical aid, it only works with a scheme underneath it, and for most members it is the cheapest thing on this site that prevents a bill they were not expecting.
The reason the shortfall exists has nothing to do with how good your option is. A scheme pays its own rate, a specialist sets their own fee, and in hospital you rarely choose the anaesthetist. Gap cover is what stands in the space between those two numbers.
Cover
What this typically covers
In-hospital shortfall
The main clause, and the reason the policy exists. Your scheme pays its rate. The surgeon and the anaesthetist charge theirs. Whatever sits between the two is yours, and in hospital you are not usually the one choosing who treats you.
The difference between the scheme rate paid for a procedure and the amount charged by the treating specialist, up to the policy's annual limit.
Co-payments and deductibles
The amount your scheme makes you pay before it pays anything at all on certain procedures. It is written into your option's rules, it is easy to forget until the hospital asks for it at admission, and this is the clause that answers for it.
Fixed amounts a scheme requires the member to carry on stated procedures, scopes and imaging, whether as a rand amount or a share of the account.
Sub-limits on named items
Some things a scheme covers only up to a number, and a joint replacement clears that number comfortably. This picks up the rest.
Cover where a scheme funds a specific item, such as an internal prosthesis or a specialised appliance, only up to a stated ceiling.
Oncology shortfalls
Cancer treatment is where schemes most often stop paying in full and start paying a share. Your option's rules say where that switch happens.
Cover for the co-payment share a scheme applies to cancer treatment once a stated point in the treatment plan is passed.
Casualty and emergency
An accident on a Sunday that ends at casualty and not in a ward. Many options pay very little towards that, because nobody was admitted, and it is one of the most common small shocks in this class.
Treatment in a casualty unit following an accident, where the visit does not become an authorised hospital admission.
The people on your membership
Usually one policy for the whole family, priced per membership rather than per person. Everyone on it has to sit on the same scheme membership, which is the detail that catches families who split their cover between schemes.
One policy covering the principal member and the dependants registered on the same medical scheme membership.
Limits
What this will not cover
It cannot work without a scheme
Gap cover tops up what a medical scheme has already paid. Leave the scheme and the policy has nothing to attach to, and where a scheme declines an account outright there is no shortfall to meet, because there is no payment to top up.
It is not a second medical aid
This is a demarcation product carrying an annual limit set by regulation, deliberately, so that it cannot be sold in place of scheme membership. The limit applies per person per year and it is worth knowing where you stand against it.
Day-to-day costs
GP visits, medicine off the shelf, dentistry and optical are day-to-day claims and belong to your scheme's savings or benefits. Gap cover follows in-hospital and defined out-of-hospital events, not the running costs of a household.
Waiting periods and what you already have
New policies carry a general waiting period, a longer one for conditions you already have, and often a separate period before childbirth is covered. The month before a planned procedure is the one time this cover will not help you.
Claim
When you claim
The scheme pays first, then you claim
There is nothing to claim until your scheme has processed the account, because the shortfall is defined by what it paid. What the gap insurer needs is the remittance advice from the scheme and the account it relates to, rather than an estimate from the practice.
The policy had to be in place before the treatment
Cover answers for events inside the period of insurance and does not reach backwards. Taking out a policy after the admission is the single most common reason a first claim fails.
Submit inside the policy's window
Every gap policy sets a period from the date of treatment within which a claim has to be lodged, and it is shorter than people assume. Send the paperwork when the scheme's statement arrives rather than filing it to deal with later.
Questions
Frequently asked questions
The shortfall is not created by your option, it is created by what the specialist charges, and the specialists who charge several times the scheme rate treat members of every option. A richer option buys you more benefits and higher limits. It does not oblige an anaesthetist to charge the scheme rate.
No. It is a short-term insurance policy sold under the demarcation regulations, which exist so that products like this cannot be marketed as a substitute for scheme membership. That is also why it carries an annual limit, and why it stops working the moment you leave your scheme.
Tell the gap insurer. The policy is written against your membership, so a change of scheme, option or dependants has to be recorded for the cover to keep matching what it is topping up. It usually carries on without a fresh waiting period, but only if it is told.
You can take it out, and it will not pay for that procedure. Waiting periods and the exclusion for conditions you already have exist precisely for this. The policy is worth buying while nothing is planned rather than once something is.