Presented by Total Risk Administrators

Medical Gap Cover: Saving the day in 2023

 ·7 Mar 2023

As South Africans, we know all about the skyrocketing cost of healthcare.

Being unforeseen and unplanned for, a minor accident could result in serious injury and potentially even call for major surgery with exorbitant medical costs. This is where gap cover comes in.

A Relatable Reality

To put things into perspective, here is a scenario of what happened to Mr Smith, 69, in January while visiting his children in KwaZulu Natal:

Whilst attempting to pack a box into a storeroom, he tripped and fell over an extension cord. Initially, he did not give the incident much thought until the back pain began setting in. He was later diagnosed with Sciatica in the lumbar region, a condition that required a spinal fusion together with a laminectomy to decompress the nerve.

Total treatment costs amounted to over R147 000.00, with the medical aid covering only a small portion of the bills (R20 251.00, to be exact).

Thankfully for Mr Smith, he had taken out medical gap cover through Total Risk Administrators, which took care of the outstanding balance.

His story illustrates the importance of investing in short-term insurance, like gap cover, to settle the shortfall between a medical scheme tariff and the applicable rates charged by private healthcare providers.

The Difference Between Medical Aid And Gap Cover

Medical aid is health cover for costs such as hospitalisation, medicine and treatment of a medical aid member. However, members’ respective costs are only covered in line with the medical aid plan they subscribe to and the general rules of their medical aid provider, often resulting in a shortfall.

In contrast, gap cover is an additional service that kicks in when the medical aid can no longer cover certain procedures and treatments.

Monthly premiums for gap cover can range from R99.00 per month to R495.00 per month, depending on your budget and choice of product.

A qualifying factor of gap cover is that you must be a medical aid member. Your gap cover will also not provide cover if your medical aid has already paid the full amount for a procedure or if your medical aid does not pay at all.

Do I Need Gap Cover If I Have Comprehensive Medical Aid?

Gap cover is by no means a substitute for a medical aid plan but is rather present to work with it and augment the health care cover.

A medical aid plan may cover healthcare costs such as doctors’ appointments, in-hospital procedures, treatment and medication. Gap cover then steps in to cover the gap between what your medical aid covers and what your doctor charges.

Gap cover is an investment, especially when you consider the following:

  1. Should you not have gap cover in place, you will often be left with high medical expenses by way of shortfalls, even if you do belong to a medical aid scheme.
  2. If you do not have gap cover, your medical aid scheme could restrict you to only using certain healthcare options.

Gap Cover Can Save You From Financial Ruin In 2023

If you are generally in good health, you may view taking out additional medical gap cover as an unnecessary expense.

However, the importance of having it might only be felt should something unexpected arise (such as in Mr Smith’s case), and you are left with a substantial payment gap that your medical aid cannot cover.

Gap cover will reduce expenses when combined strategically with medical aid

For example, by investing in a premium gap cover product whilst simultaneously belonging to a more affordable medical aid scheme, you could effectively balance out the monthly costs for healthcare and still be left with adequate cover in the event of an emergency.

In short, gap cover is a cost-effective way of safeguarding yourself and your loved ones against the financial burden that medical bills can incur. More important, gap cover provides you with the choice of being treated by private healthcare specialists, minus the hefty medical bill.

Gap cover options provide cover for prescribed minimum benefits (PMBs) and will cover co-payments per family, per year, up to a certain amount.

Most gap cover providers offer essential benefits such as in-hospital specialist gap cover and medical co-payments often imposed by medical aid schemes. Some gap cover options will also pay for certain out-of-hospital procedures, such as MRIs and CT scans.

Choosing A Gap Cover Provider In 2023

Investing in gap cover in 2023 allows you to not only reduce the cost of your monthly premiums but also save money when you need it most in the long run.

Suffice it to say; medical gap cover could prove life-saving in the case of an unforeseen health emergency, especially given the current economic climate and the obvious shortcomings of the South African public healthcare system.

Get in touch today to find a gap cover policy that not only suits your individual needs but meets your budget too.

Note: A general three-month waiting period might be imposed by certain gap cover providers. However, gap cover companies such as Total Risk Administrators do not set a waiting period.

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