Your money: Everything you need to know about medical gap cover

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Photo: Gallo Images/Getty Images
Photo: Gallo Images/Getty Images

Even if you’ve taken out extra medical insurance you may still be caught short if you land up in hospital.

Your doctor has broken the bad news to you: that dull ache you’ve been feeling in your stomach is appendicitis. Now you’re in hospital waiting to have your appendix removed, but as you’re wheeled into theatre there’s one thing that keeps bugging you – and it has nothing to do with the size of the anaesthetist’s needle.

How will you pay for all of this?

For many people – even those with medical aid – the pain of surgery is nothing compared with how they feel when they get the bill for their hospital stay. Costs can be up to five times the prescribed medical aid rate and it’s the poor patient who has to cover the difference.

That’s why lots of medical aid members now opt for gap cover. It’s a separate insurance that covers the shortfall between what medical funds pay and what hospitals and doctors charge.

But if you go this route, be sure to read the fine print carefully as gap cover specifically excludes certain procedures and medical conditions.

Exclusions differ between insurers but in general gap cover works like this

1. Gap cover pays only the shortfall between medical costs and what’s covered by your medical aid. For example, your op costs R60 000 but your fund pays only R25 000 – your gap insurance should cover you for the remaining R35 000. But if you’ve exhausted all your cover for a specific condition and your medical aid doesn’t cover the full bill, gap cover won’t kick in either. It also won’t cover you unless your medical aid has approved hospital admission and given you an authorisation number.

2. Gap insurance generally doesn’t cover cosmetic surgery, obesity treatment, laser eye surgery, dental implants and fertility treatment. So if you have a tummy tuck or a nose job, the gap cover probaby won’t pay. But it may cover medically necessary procedures such as facial surgery after an accident or reconstructive surgery after a cancer-related mastectomy. 

3. Self-inflicted wounds, treatment for alcohol or drug addiction or suicide attempts aren’t covered. So if you’re hospitalised because of drug use, legal or otherwise, your gap cover won’t pay out – unless you took the medication according to a medical practitioner’s prescription and had a bad reaction.

4. Gap cover insurers differ in the way they cover psychiatric treatment. In general, expenses related to depression, emotional or mental illness or stress-related illness won’t be covered.

5. Unless specifically stipulated in your policy, it won’t pay for medical expenses outside South Africa’s borders.

Photo: Gallo Images/Getty Images
Photo: Gallo Images/Getty Images

6. When you take out the insurance there’s usually a waiting period during which you won’t be able to claim.It varies between insurers, but generally works like this:

  • A general waiting period of three months applies. More comprehensive (and therefore more expensive) plans might not have this waiting period. 
  • There might be an automatic waiting period of 12 months for any claims relating directly or indirectly to pregnancy, hysterectomy, joint replacements, cataracts, tonsil extractions and nose procedures such as adenoidectomy, hernia procedures and reflux surgery. 
  • There are usually waiting periods for pre-existing conditions such as back and neck injuries, and cancer and heart conditions that were diagnosed 12 months before the gap cover was bought. Depending on the insurer, these conditions won’t be covered in the first six to 12 months of the policy being taken out, or there’ll be no claims paid in the first six months, but in the following six months 50% of a claim will be paid.

7. Generally, gap cover doesn’t include services rendered by allied health professionals such as dietitians, audiologists, chiropractors, speech therapists and occupational therapists. But some insurers will cover in-hospital physiotherapy.

8. Injuries resulting from certain adventure sports such as skiing, mountain-climbing or scuba diving aren’t covered.

9. Gap cover generally excludes consultations before or after in-hospital treatment, medicine and disposable items in and out of hospital, crutches and wheelchairs.

10. Many people think once their medical aid savings are exhausted they can use gap cover to pay the rest of the year’s day-to-day claims. This isn’t correct. Gap insurance is there to protect you if you land up in hospital by supplementing your existing medical aid cover

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