What is GAP medical cover?

For residents in South Africa, gap medical cover can be essential in ensuring the continued good health of yourself and your family. Designed to cover the ‘gap’ between what your care practitioner charges and what your medical aid will pay, it means you need never find yourself in a situation where you’re worrying about whether you can afford the treatments you require.

At Money Expert we personally recommend that every individual should have it, but we don’t just expect you to take our word for it. Providing a look at the ins and outs of gap medical cover, as well as how it works, this article contains all you need to know to make an informed decision on whether it’s right for you.

In This Guide:

What is GAP cover?

Before you make a choice one way or the other, it’s important that you understand what gap cover actually is. Designed to cover any discrepancies between the amount charged by your healthcare practitioner and the sum your medical aid provider is willing to pay, it means you never have to worry about whether you can afford necessary treatments.

The way it works is perhaps best illustrated by an example. Imagine, for a moment, that you’re admitted to hospital with appendicitis. While your medical aid covers your hospital stay, doctors’ fees, the cost of anaesthesia, medicine, and supplies, your plan stipulates that it will only payout for a certain percentage, meaning you have to either stump up the rest or find an alternative solution.

It is here that gap cover comes into play, covering the shortfall so your own finances remain unaffected.

Do I need GAP cover?

While the decision to take out gap cover should always be based upon your individual circumstances, we personally recommend that anyone without limitless funds to fall back on should consider it. This is because of the combination of private healthcare rates and inflation that we’re currently seeing in South Africa, which can quickly cause necessary medical costs to become unaffordable to the average citizen.

What is covered by GAP cover?

Gap cover is often wide-ranging, but there are still some things that may be excluded from your plan. Although the specifics of this will be dependent on your provider, treatments that are not usually covered include:

  • Treatments for obesity, such as stomach stapling
  • Treatments for cosmetic surgery, unless necessitated by either trauma or oncology treatment
  • Specialised dentistry
  • Fertility treatments
  • Anything that isn’t covered by your medical aid

That being said, no two policies are the same, so it’s important to check the specifics of any cover you might take out before signing on the dotted line.

Am I eligible for GAP cover?

As we mentioned above, we believe that those who are eligible for gap cover should seriously consider their options, but that being said, there are some who will find that they’re not able to take out a policy even if they wish to. This is because, in order to qualify, you will usually need to be an existing member of a registered medical aid scheme and below 60 years of age. If you fail to meet either of these criteria, gap cover is unlikely to be an option for you.

How do I make a claim?

If you’re considering taking out gap cover, you might be wondering how you make a claim. Thankfully, the process is usually relatively simple. Your claim will need to be submitted within six months of the medical event, with a submission form needing to be sent to your provider within this time frame.

Further details of this will be available on the provider’s website, where you will also find that you can download a claims form if you don’t already have one (these should be included along with the information pack you received when you initially took out your cover).

Once you have filled this in, certain documents will be required to process your claim, such as receipts from your healthcare practitioner, relevant doctors’ accounts, hospital documents showing admission and discharge times, and your current medical scheme membership certificate.

These will help your provider to verify your claim, so that they can settle it quickly and efficiently and transfer your payment across to either your medical provider or your own bank account.

Isn’t it time you considered taking out gap cover for you and your family? With our handy tools to help you compare medical aid, it’s never been easier!

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