What is Gap Cover and Why Do You Need It?
Ever felt that sinking feeling when you realise your medical aid doesn't cover the full cost of a procedure? Imagine needing surgery that costs R90,000, but your medical aid only covers R30,000. That leaves you with a jaw-dropping bill of R60,000 to pay out of pocket.
Medical expenses in South Africa can be astronomical, and while medical aid is there to help, it doesn’t always cover the full amount. That’s where gap cover steps in: a financial safety net designed to keep you from paying huge out-of-pocket in-hospital expenses.
But what exactly is gap cover, how does it work, and why should you consider getting it? Let’s break it down in simple terms.
Let’s Talk About Medical Aid Rates
Understanding how medical aid rates work is key to understanding the need for gap cover. Medical aid providers set a rate, called the medical scheme tariff (MST), that they are willing to pay for different treatments and procedures. The problem? Many healthcare providers charge well above these rates, sometimes up to 500% more.
Medical aids in South Africa typically cover between 100% and 300% of the MST, depending on your plan.
Read more; Medical Gap Cover Glossary
Let’s say your medical aid covers a in-hospital at R101,000, but the total cost is R153,000. Without gap cover, you’d be responsible for paying the remaining R52,000 out of pocket.
Even if you have a top-tier medical aid plan, there are often co-payments, sub-limits, that can leave you with a hefty bill. This is where gap cover can make all the difference, ensuring you’re not caught off guard by unexpected expenses.
Something to Fill the Gap
Gap cover is a short-term insurance product that fills the gap between what your medical aid pays and what your healthcare provider charges for in-hospital procedures. It’s designed to prevent you from having to dip into your savings or take on debt just to afford medical treatment.
Benefits vary depending on the gap cover providers and can include:
- Tariff Shortfall Cover: Pays the difference between what your specialist charges and what your medical aid covers, often up to 500% above MST.
- Co-Payment Cover: Covers additional fees required for procedures, such as MRI or CT scans, which many medical aids only partially cover.
- Sub-Limit Cover: Helps with costs when medical aids impose limits on certain treatments, like internal prosthetics or ICU stays.
- Oncology Benefits: Covers shortfalls in chemotherapy, radiation therapy, and other cancer treatments.
- Casualty Cover: Covers emergency treatments that may not be fully covered by medical aid.
- Additional Benefits: Some providers offer trauma counselling, maternity cover, or lump-sum pay-outs for serious illnesses.
It’s important to note that gap cover is not a replacement for medical aid—it works alongside it. If you don’t have medical aid, you won’t qualify for gap cover.
Gap Cover Comparison
| Provider | Monthly Premium | Coverage Above Scheme Tariff |
|---|---|---|
| Total Risk Administrators | From R99 | Up to 700% |
| Dis-Chem Health | From R152 | Up to 600% |
| Zestlife | From R253 | Up to 500% |
| Stratum Benefits | From R197 | Up to 500% |
| Sirago | From R172 | Up to 500% |
Note: Premiums and benefits are subject to change. Always consult directly with providers for the most current information.
What About Waiting Periods?
Understanding the waiting periods imposed by different gap cover providers is crucial when selecting a policy. Below is a comparison of the waiting periods for the gap cover providers listed in the table above:
Total Risk Administrators
No general waiting period. 10-month waiting period for specific procedures, including spinal surgeries, hernia repairs, endoscopic procedures, pregnancy and childbirth, joint replacements, and more. 6-month waiting period for pre-existing conditions that may lead to hospitalisation (excluding cancer).
Dis-Chem Health
3-month general waiting period (accidents exempt). 12-month waiting period for pre-existing conditions.
Zestlife
No general waiting period. 12-month waiting period for pregnancy and cancer treatment. 9 to 12-month waiting period for pre-existing medical conditions.
Stratum Benefits
1-month general waiting period (without GP Pre-Auth Waiver). 2-month general waiting period (with GP Pre-Auth Waiver). Specific waiting periods for pre-existing conditions are not specified.
Sirago
3-month general waiting period (accidents exempt). 6-month waiting period for specific procedures like myringotomy, adenoidectomy, tonsillectomy, hysterectomy (unless due to malignancy), and spinal or joint-related procedures (unless due to an accident). 10-month waiting period for pregnancy and confinement. 10-month waiting period for any pre-existing conditions, diseases, or illnesses.
Note: Waiting periods vary by provider and can change over time. Always check directly with the provider for the latest details.
Read more: Gap Cover Frequently Asked Questions
Compare Quotes for the Best Gap Cover in South Africa
Medical expenses are unpredictable, but being prepared can save you financial stress in the long run. Gap cover ensures that when life throws unexpected medical bills your way, you’re not left scrambling to pay them.
Instead of spending hours researching individual gap cover options, let us do the heavy lifting. Our online comparison tool allows you to compare quotes from leading gap cover providers in South Africa, helping you find the best plan for your needs and budget.
This article is for informational purposes only and should not be construed as financial, legal or medical advice.
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