What is Gap Cover, and do I really need it?
About GAP Cover in South Africa
Gap Cover can help you to save thousands when it comes to these unexpected costs! Have you, a family member or a friend had to pay extra towards a hospital treatment even after your comprehensive medical scheme has paid out? These extra payments often amount to many thousands of rands, and place a lot of unplanned stress and pressure on an individual and their families.
There is a common misconception among medical scheme members, and many people are finding themselves in financial difficulty after a planned or unplanned visit to the hospital. When a medical scheme member is told they are "covered up to 100%" (or 200% or 300%) of their medical scheme health rate", they often believe they are covered for 100% of their hospital bill. Unfortunately this is far from the truth...
Medical schemes set their own health rate for medical services, which is often far less than what the actual specialists are charging in-hospital. The specialist who attends to you in hospital is not obliged to charge in-line with the medical scheme's rate, and more often than not can charge up to 500% more than what your medical scheme is prepared to pay. This creates a large shortfall between the actual cost of a procedure / treatment and what your medical scheme pays. This shortfall then becomes the member's responsibility, and unless you have additional cover for this, then you will have to pay out of your own pocket.
Gap Cover is a form of medical insurance that covers this shortfall, and is relied on during in-hospital treatments that range from emergency care to planned procedures and childbirth. Exclusively designed for medical aid members in South Africa, Gap Cover works in conjunction with your existing medical scheme to "top-up" the shortfall on approved in-hospital procedures.
With the cost of living in South Africa increasing steadily over the last few years, and an ever-increasing gap between what specialists charge and medical schemes pay for in-hospital procedures, we believe Gap Cover is no longer a luxury or an optional extra for medical aid members. It has become an essential part of medical cover, and CompliMed is committed to making Gap Cover as affordable and accessible as possible for all medical aid members.
As experts in the Gap Cover industry, CompliMed has been helping individuals and their families cover their medical scheme shortfalls in times of need since 2003. Our new Legacy Series product will provide you with peace of mind and comprehensive cover for almost every potential shortfall you may experience.
Designed for the modern South African medical aid member, CompliMed Gap Cover products are affordable, accessible, easy to understand and simple to claim from.
Common Medical Aid Shortfalls
There are a number of situations in which you can suffer a shortfall when undergoing an in-hospital procedure or treatment. Below are some of the most common reasons for a shortfall which you may not be aware of.
- Tariff charge shortfall: The specialist charges beyond what your medical scheme is prepared to pay for a particular procedure.
- Hospital admission co-payment: Your scheme may require that you pay a co-payment to the hospital on admission.
- Procedure co-payments: There are a number of procedures where certain medical schemes apply a co-payment. This means that you become liable for these co-payments. An example would be where a co-payment is applied for an MRI/CT scan.
- Sub-Limit shortfalls: Some in-hospital procedures have an overall annual benefit limit applied to them by your medical scheme, meaning that should you undergo that particular procedure and the actual cost goes beyond this limit, you will be liable to settle the outstanding amount yourself. An example of a sub-limit that is applied by the scheme is cover for prosthesis (incl. knee and hip replacements, permanent pacemakers, etc.)
- Oncology treatment: Depending on your medical scheme option you may have limited oncology treatment cover, either by limiting the amount of cover they provide on an annual basis or where they apply a percentage co-payment for any treatment you receive beyond your annual cover limit. An example of this would be where a scheme has an annual oncology limit of R200,000. In the unfortunate event that you require further/ongoing treatment after having breached this annual limit, you will be liable for a 20% co-payment for the remainder of the year.
- Casualty care: In the event of an accident that requires you to make use of a casualty facility of a registered hospital, you will find that your medical scheme does not provide cover for this event. In general, your medical scheme will cover you once you are admitted into a hospital ward. Casualty is not deemed to be a hospital ward hence the reason why it is not covered.
Examples of actual Gap Cover claims
Hip Replacement Claim
- Total Procedure Cost – R64,571.28 = 100%
- Amount Covered by Medical Aid – R16,326.30 = 25%
- Amount Covered by Gap Cover – R46,361.39 = 75%
Rugby Injury Claim
- Total Procedure Cost – R29,993.90 = 100%
- Amount Covered by Medical Aid – R9,146.90 = 30%
- Amount Covered by Gap Cover – R19,987.00 = 70%
Spinal Discectomy Claim
- Total Procedure Cost – R101,302.42 = 100%
- Amount Covered by Medical Aid – R34,343.42 = 34%
- Amount Covered by Gap Cover –R66,959.00 = 66%
Caesarean Section Childbirth Claim
- Total Procedure Cost - R35 808.39 = 100%
- Amount Covered by Medical Aid - R7 323.64 = 20%
- Amount Covered by Gap Cover - R28 484.75 = 80%
Impacted Wisdom Teeth Claim (In-Hospital)
- Total Procedure Cost - R28 823.11 = 100%
- Amount Covered by Medical Aid - R16 978.81 = 59%
- Amount Covered by Gap Cover - R11 844.30 = 41%
Note: The Total Procedure Cost = Specialist fees for performing the specific in-hospital procedure.
Disclaimer: The above examples are an indication of what shortfalls you could possibly encounter when being hospitalized and are based on a number of factors, namely the rate at which the specialist charged, your medical scheme option and your Gap Cover policy benefits. Any future gap claims will be assessed on its own merits using the claim documentation submitted and the Gap Cover benefits contained in the master policy document.
CompliMed® Gap Cover - Affordable, Comprehensive & Simple to Sign Up!
If you are not protected against a potential shortfall with your medical scheme, or are looking to move your existing Gap Cover to us, our new Legacy Series product covers almost every potential shortfall you may experience.
Simply sign up using our online application form, and get comprehensive Gap Cover protection for the whole family.
2024 Monthly Premium:
per family for under 65yrs
per family for 65yrs+
- Medical Expense Shortfall Cover
- Co-Payment Cover
- Non-DSP Hospital Penalty Cover
- Sub-Limit Cover
- Trauma Recovery Cover
In-Hospital and Out-Of-Hospital Benefits
- Traditional Cancer Cover
- Biological Cancer Drug Cover
- MRI and CT scan cover
- Trauma care cover
- Breast Cancer Prevention Cover
- Breast Cancer Reconstruction Cover
- Innovative Cancer Drug Cover
- Investigative Treatment
- Co-Payments for MRI, CT and PET Scans
- Co-Payments for scopes
- Sub-Limit Cover for MRI, CT and PET Scans
- Casualty Benefits for accidents
- Casualty Benefits for illness
In-Hospital Dental Cover
- Medical expense shortfall cover
- Co-payment cover
- Sub-limit and co-payment cover for dental implants
- Sub-limit cover
- Basic Dental Medical Expense Shortfall for Children
- Cancer Diagnosis Benefit
- Medical Scheme Contribution Waiver
- GAP Premium Waiver
- Personal Accident Benefit
- Critical Illness Benefit
- International Travel Cover
- A 3-month general waiting period applies to all benefits (except in the event of an accident, which occurred while on the Policy). In the event the commencement date of the Policy is the same as the commencement date of the Medical Scheme, no 3-month general waiting period will apply to Medical Expense Shortfall Cover (increasing the medical aid rate up to 600%)
- A 10-month waiting period on pregnancy/childbirth
- A 12-month waiting period on investigations, treatment or surgery for: hysterectomy, hysteroscopies, endometriosis, ovarian cysts and fibroids (myomectomy), muscular-skeletal (except in the event of an accident, which occurred while on the Policy), tonsillectomy, myringotomy, grommets, adenoids, wisdom teeth, hernia, cataracts, gastroscopies, sigmoidoscopies, colonoscopies, cancer, nasal and sinus.
- Waiting period concessions will apply should your existing policy be in force for a period of 12 months and longer.
New Policy Waiting Period
Existing Policy Transfers
Get confirmation of cover within 48hrs!