Q:Is there an overall limit to how much I can claim?
Yes, and it is set by the regulator.
Currently, the limit is R210,580 per person although this limit usually gets increased slightly every year in April. Some benefits, like premium waivers and payouts on death do not fall into this limit.
There are also sublimits for various claims. These limits can be per year, or per event and per person or per family. Example: Ambledown 100 limits ER visits to R11,000 per person per year. Sublimits are still subject to overall limit of R198,660 unless otherwise stated.
Q:Who can be on my policy?
Gap covers do not automatically cover everyone on your medical aid plan.
Although each gap product has its own rules, generally a gap covers main member, spouse, and dependant children, as defined by the gap “family unit” rules.
Just because a medical scheme recognises your adult child as a dependant (eg. because they are studying), does not mean that the gap will automatically apply the same rules.
Most gaps consider children as dependants up to age 21, and extend that up to age 26 or 27 if they are full time students. Adult children or children on their own medical plan need their own gap cover.
If you have your elderly parents on your medical aid plan, they will almost always need their own separate gap policy.
Tip! You and your spouse can be on separate medical aids plans but still be covered by one gap policy. This is useful if you and your spouse are on different plans due to employer rules, for example.
Q: Are there age limits?
Unlike medical aid schemes, Gap covers are allowed to deny membership based on age. Those that do can limit membership to a certain age group (most often 65yrs and younger), and some charge a premium for older members.
Some gap covers are available specifically to a younger age group, to account for lower health risk and thus lower premiums. Example: Stratum has lower premiums for under 35yr olds.
Q: Is there a perfect gap cover for every medical aid plan?
That’s subjective, and depends on your needs and risk level, but the answer is probably “yes”. Also, some gaps are designed for specific medical aid plans. Example, Ambledown LPE policy is designed for Keycare plans that exclude certain procedures. Discovery Insure gap plans are designed specifically for Discovery Health medical aid plans.
Q: When can you change gap covers?
At any time.
You just need to give the required notice (usually 31 days), and be aware of any waiting periods on the new cover. You can keep your old cover while the new one is activated or during your waiting period.
Q: Can you belong to more than one gap cover?
There’s nothing in law that says you cannot, but your gap cover rules might not allow it.
Either way, even if you do belong to more than one gap cover you cannot “double-claim” for the same medical event. That is known as “enriching” yourself, and is not legal.
On the other hand, if you are switching gap covers and your new cover imposes a 3 month general waiting period, you might want to keep the old cover during that time.
Reminder: you cannot belong to more than one medical aid at the same time!
