What is gap cover?

Medical schemes have pre-set limits of how much they will charge a health care provider for an in-hospital procedure. This is known as the “scheme rate” or the “scheme tariff”. The problem is that most specialists are charging much more than this rate, and you have to pay the difference out of pocket or find a specialists who will charge what the scheme is willing to pay.

Gap cover will pay the difference between what the medical aid will pay, and what the doctor charges. Gap cover can also pay any co-payments required, or increase sub-limits imposed by your scheme.

Let’s look at an example.

John has a procedure to treat a gallbladder problem. His specialist charges R3,500 for this procedure, and the anaesthetist charges R4,500. However, the scheme rate for each doctor is only R2,000 and R3,000 respectively. John has to pay the difference – R3,000 – himself. In addition, there was a R1,500 co-payment for the procedure that he needed to pay to the hospital. John is R4,500 out of pocket.

But John has a gap cover product, which covers all these shortfalls. So, actually, John is not out of pocket at all!

AskAdam Gap cover

We have worked closely with Ambledown Financial Services to develop three unique gap products that offer the perfect balance of benefits and price. These products are unique to rehealth.co.za and are sold by MC De Villiers brokerage (FSP NO. 7241). You can apply for them online.

Basic rules of how a gap cover works

  • Gap cover is a short term insurance product, and the maximum allowed payout per person per year is R150,000.
  • You need a medial scheme membership to qualify for gap cover
  • There is guaranteed acceptance to the gap cover, although a higher premium is charged if a member or dependant is older than 64
  • Premium is per family, not per person
  • The cover cannot be cancelled or not renewed by the insurer, unless you don’t pay premiums or there has been fraudulent activity
  • There is a 3 month general waiting period and a 12 month exclusion on pre-existing conditions. No waiting period if you are moving gap covers. Find out more here.

Who can be covered?

  • Principal member and immediate dependants that are registered as dependants on principal member’s scheme
  • One spouse
  • Eligible children ie Natural, adopted, step child and fostered who are unmarried and under the age of 21yrs
  • Maximum allowed age of children can be extended to 26 if unmarried, fully financially dependant on principal member and a dependant on the principal member’s medial aid

Example of who is not covered?

  • Parents
  • Relatives

Other articles about AskAdam gap cover

For more information on the gap product, please read the articles below, or contact us with any questions.

The AskAdam gap products are not a medical scheme, and the cover is not the same as that of a medical scheme. The policy is not a substitute for medical scheme membership. The master policy issued is the source of all benefits, and obligations and exclusions.

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