Medical treatment at private institutions can create serious medical expenses – are you able to afford this treatment out of pocket? Part-4 of our “5 problems in life” series – we will look at medical expenses, how medical aid schemes pay for treatment and what gap cover is. Having gap cover in place could be the most rewarding decision you make, especially if the worst were to happen.
Medical Expenses – Medical Aid generally only covers a portion of the bill; can you afford the difference out of pocket?
Medical aid schemes, in South Africa, provide cover for their members’ medical expenses upon paying a monthly contribution fee. The cover medical aid provides for is hospitalization, certain treatments and medicines. However, medical aid does not always cover the full costs of care and treatment received at private hospitals – this is where it is important to have Gap cover in place. Gap cover helps bridge the cost gap between what health care institutions charge and what medical aid schemes are willing to pay for that treatment.
- What is gap cover and how does it work?
Gap cover is a complementary insurance policy to an individual’s medical aid scheme. Gap cover provides cover for expenses that occur when medical practitioners charge more than the medical aid rates for treatment. It is important to note that gap cover is not a medical aid scheme and it will not cover any treatment expenses that your medical aid scheme does not cover. In order to qualify for gap cover – you must be a member of a registered South African Medical aid scheme.
Gap cover and medical aid schemes are not governed by the same laws and as such have different regulatory requirements for instance, the medical aid will reimburse the health care provider for the expenses incurred whereas gap cover reimburses the individual who then must take responsibility to pay the service providers. Claim submission and processing are also separate. Generally, a gap cover claim is submitted after your medical aid has paid out. You can also retain the same gap cover even if you switch medical scheme providers.
- Why should you look at gap cover?
Medical aid schemes provide between 100% to 300% cover on the scheme rates. Doctors and medical practitioners are able to charge rates dictated by them and could be anywhere between 200% and 500% of medical scheme rates. Since medical aid will only pay according to the agreed scheme rates – gap cover should not be seen as a luxury but a necessity to safeguard you from financial ruin should the unthinkable happen.
No matter the level of cover that medical aid scheme provides for you – you should really consider gap cover. Having gap cover in place can put your mind at ease knowing you will be covered should some unfortunate event put you in the hospital.
