Gap cover explained

Your medical aid pays specialists at a set rate (often called the scheme rate or a multiple of it). Many in-hospital specialists charge well above that, sometimes 200% to 500% of the medical aid rate. The portion your scheme does not pay is the shortfall, and you are liable for it. On a big operation that can run into tens of thousands of rand.

Gap cover typically pays:

• The shortfall between the specialist's bill and what your scheme pays for in-hospital treatment
• Co-payments and deductibles on certain procedures (depending on the policy)
• Some define sub-limit top-ups for things like cancer treatment or internal prosthetics

It pays you or the provider the difference, up to an annual limit set per person.

Gap cover is not medical aid and cannot be used on its own. It generally does not cover:

• Day-to-day costs like GP visits and out-of-hospital medicine
• Procedures your scheme declined entirely
• Costs above its own annual limit

You must have an active medical scheme for gap cover to respond to a claim.

Gap cover policies usually carry their own waiting periods - commonly a short general waiting period and a longer one (often up to 12 months) for pre-existing conditions and some events like childbirth. There is also a legislated maximum amount it can pay per person per year. Read the policy schedule carefully, because terms vary between insurers. Some advertise no general waiting period, which is worth confirming in writing.

Gap cover is often good value because the monthly cost is small relative to the shortfall risk on a single hospital admission. It is most useful if your plan uses specialists who bill above scheme rates, or if your plan has co-payments on common procedures. Compare a few policies on limits, waiting periods and exclusions rather than price alone.