What you need to know about Gap Cover

Gap cover is supposed to cover the deficit between your private healthcare professionals’ rates and the cover your medical aid rate provides. Usually, medical aid companies in South Africa cover 100%, 200% or 300%, but some specialists can charge far more.

Here we speak to several experts about gap insurance and whether it sufficiently ‘fills the gap’ between what a specialist can charge and what your medical scheme covers. We also answer some frequently asked questions about gap cover.

Am I covered in full right from the start? 

Full cover from the start of the plan doesn’t always apply. Most providers will impose a three-month waiting period. ‘This would not apply to valid claims resulting from an accident,’ adds Michael Emery, marketing executive of Ambledown Financial Services.

Pre-existing medical conditions can also inhibit what you’re covered for. If you have a pre-existing condition and you have received treatment or advice up to 12 months before joining gap cover, your provider may impose a 12-month waiting period during which time you may not claim against this condition on your new policy. If you decide at some later date to upgrade or downgrade your policy and the new policy has new benefits, the provider may decide to apply a 12-month waiting period,’ says Emery.

You may also not be covered for any procedure not covered or authorised by your medical scheme. ‘Make sure that you check your policy for the cover provided. It is very important to understand the exclusions, as well as the terms and conditions in your policy document,’ advises Emery.

How can I ensure I’m getting the best gap cover deal?

There are various ways of applying for gap cover. You can choose to take out a product online or go through a broker. There are advantages to going through a broker. ‘There are also brokers who do have in-house products that have been designed and cost for particular broker houses and these could be relatively cheaper based on the risk profile of the broker house. There is no cost saving for a member whether they go directly or through a broker, as the commission payable is built into the product for the broker.

‘The advantage of going through a broker is that the broker is there to fight for the member in case of an escalated query or concern, which then alleviates the problem of fighting with the company for the member. The brokerage also ensures that all administration, such as change of bank details, etc., is also done and they will generally ensure that this is followed up and sorted for the member,’ says Melody Perotti, healthcare and employee benefits manager at Saint Andrews Brokers.

The terminology associated with gap cover can be confusing. If you don’t know how the online product works, it’s best to consult a broker. ‘It is easy for anyone to go online a pull a benefits guide for each gap cover option; what is not easy and takes a lot of experience in the industry is to ‘plug’ the right shortfalls. This expertise, knowledge and time are worth the commission on each gap cover that providers pay brokers. It is not easy to navigate the terminology medical aids use and understand how they apply their limits, co-payments and shortfalls on specific procedures,’ explains Westley Van Rooijen, head of healthcare at Austen Morris Associates.

Will gap insurance cover the whole family?

This depends on what the gap cover provider offers. ‘Most gap covers provides cover for immediate family (the policyholder’s spouse and eligible children). Adult children would have to have their own gap cover policy in place, even though they may be financially dependent on the policyholder and registered as dependents on their medical scheme.

‘Grandchildren will be covered only if they have been legally adopted or fostered. Different gap cover providers have different definitions for a family, so make sure you check how the family is defined in your gap cover policy,’ explains Emery.

How do I reduce my medical insurance fees?

Study how much usage you get out of your medical scheme and consider what you can afford. A Gap cover could offer some help. ‘There may just be a gap cover appropriate to cover the shortfall in hospital when downgrading your medical aid. The common misconception the consumer has is that all medical aids are the same. This could not be further from the truth; consumers will unknowingly and voluntarily forfeit much-needed benefits to save money,’ points out Van Rooijen.

How do I complain if I’m not happy with my Gap cover provider?

Emery says: ‘It is a legal requirement for insurers to include an escalation process when informing you of their decision when assessing a claim. This process includes an opportunity to question the decision with the insurer. If you are still not satisfied with the response, you may then escalate your complaint to the Ombudsman (details are provided in your policy document). In addition, the claims and escalation process will be detailed in your policy document.’