Medical Aid Gap Cover or Medical Shortfall Cover

What is Gap Cover?

Gap Cover provides a benefit equal to actual cost limited to 4 times the NHRPL (National Health Reference Price List) less payment for treatment received for services rendered by doctors and/or specialists while hospitalized as an inpatient.

Gap Cover is a product underwritten by Western National Insurance Company Limited.

Who can apply for Gap Cover?

Gap Cover is available to individuals currently on a medical scheme and 65 years of age or younger.

What does Gap Cover cost?

Option 1: R95 per month (max benefit / year R1 000 000 - 4 x NHRPL)
Option 2: R80 per month (max benefit / year R150 000 - 4 x NHRPL)
(For individuals who qualify, irrespective of family size.)

Why Gap Cover?

In most cases, members have a shortfall between what the medical scheme pays and the actual cost, because the Service Providers are entitled to charge more than the National Health Reference Price List (NHRPL) rates. The shortfall then becomes the member's responsibility and he/she will therefore need to have additional cover in these circumstances.

Some Hospital and Comprehensive Medical Plans offer cover at 100%, 150% or 200% of NHRPL rates for hospitalization only, while the actual costs could be more than 400% of NHRPL. Gap Cover will cover the difference between what your medical scheme will pay and the actual cost of in-hospital doctor's bills up to a maximum of 400% of NHRPL.

Waiting Period
Incurred for a period of 3 months from inception date except in the event of emergencies.
Maternity benefits will only accrue after a 12-month waiting period.
12-month general waiting period on pre-existing conditions.

Please Note
Confirm benefits covered, exclusions and the rules of the specific medical scheme, as Gap Cover cannot cover shortfalls within overall annual hospital limits or co-payment on certain procedures, as stated by the medical scheme rules.

Should your scheme have an annual hospitalisation limit, Gap Cover will not be liable to pay the difference between what your scheme covers and the cost of the account.

Example
If the medical scheme specifies that it will cover R10 000 for a prostheses, the member undergoes a knee operation and the prostheses costs R25000, Gap Cover will not be liable to pay the difference.