In theory, gap covers literally cover the gap between what your doctor charges, and what the medical aid pays. In practice, things are of course not that simple, and the fine print can get a bit tricky.
Aside from the clearly stated exclusions, there are some non-benefits that might slip through the cracks if you do not read your policy document carefully. Two issues seem to cause the most problems for policy holders:
Out of hospital claims
In order to save costs, medical aid schemes are encouraging procedures to be done outside the hospitals. This is common for scopes, for example. But many gap covers only pay towards a claim if the procedure is done in-hospital. So watch out for that.
Required contribution from medical aid
If a medical aid declines a claim because you do not have that benefit on your plan, gap cover will (almost) never pay either. But sometimes medical aid recognises a procedure or service as legitimate but cannot pay any portion of the claim because you have no more funds or benefit available. This is common with MRI scans, for example, where medical plans often have a strict limit.
The question for your gap cover is: if the medical aid does not pay anything due to lack of funds available, will your gap cover pay the full claim? Very often the answer is a surprising “no”.
To complicate matters even further, some gaps require the payment from medical aid to have come from risk (i.e, paid by scheme) not savings.
Let’s look at an example for how this can play out:
Assume you have a R10,000 medical aid benefit for MRIs, with a R2,500 co-payment per scan, and a gap cover that pays co-payments and shortfalls.
Case 1
You need a minor MRI that costs R4,000 plus the co-payment. Medical aid pays the R4,000 claim, and gap cover pays your co-payment.
You then need a major MRI that costs R13,000. Medical aid pays out the balance of your benefit (R6,000) and gap cover pays the R7,000 shortfall as well as the co-payment.
Case 2
Let’s reverse the sequence now: start with the major MRI that costs R13,000. Medical aid pays R10,000 towards the claim, and gap cover pays your R3,000 shortfall and co-payment.
Then you need the MRI that costs R4,000. Medical aid does not pay, because there is no more benefit available. Gap cover also does not pay, because medical aid did not pay. You’re R4,000+R2,500 out of pocket!
Other possible exclusions:
- Hospital fees, consumables, blood transfusions (Some exceptions: some Stratum gaps)
- Services of allied professionals such as dieticians or biokineticists
- Out of hospital procedures. A lot of products are adding this as a standard benefit now, but don’t assume unless it’s stated.
- Procedures not authorised by medical aid schemes (such as cosmetic surgery). Cancer related breast reconstruction is a possible exception.
- Procedures excluded by medical aid scheme. Some exceptions: there are gap products designed to cover procedures specifically excluded by your plan.
- Procedures where there is no remaining medical aid benefit.
- Procedures where medical aid contribution is paid from your medical savings account.
- Procedures excluded by gap cover policy (Read the policy document!)
- Procedures falling into gap cover waiting period.
- Avoidable penalties, such as for not pre-authorising a procedure.
