Medical Aid Gap Cover or Medical
What is Gap Cover?
Gap Cover provides cover for the medical shortfalls that could occur
when the medical service provider charges more than what the medical
scheme tariff for hospital procedures are. These shortfalls
would be for the medical scheme members own account. Another benefit
is CoPay Cover, a benefit for the co-payments which medical schemes
can impose on certain in- and out-of-hospital procedures.
Gap Cover is a product underwritten by Western National Insurance
Who can apply for Gap Cover?
Gap Cover is available to any member of a medical scheme that is
registered at the Council for Medical Schemes in South Africa. There
is no age limit.
What does Gap Cover cost?
Option 1 – Gap Cover only: R150 per family, per month
Option 2 – CoPay Cover only: R70 per family, per month
(limited to R10 000 per event)
Option 3 – Gap Cover & CoPay Cover: R200 per family, per
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 medical scheme tariff. The
shortfall then becomes the member's responsibility and could leave
him/her out of pocket.
Some Hospital and Comprehensive Medical Plans do offer cover at
100%, 150% or 200% of the medical scheme tariff, while the actual
costs could be more than 500% of that set tariff.
The medical schemes are also allowed to impose co-payments on
certain in- and out-of-hospital procedures, also an expense for the
members’ own pocket.
Gap Cover offers cover for the difference between what your medical
scheme will pay and the actual cost of in-hospital doctor's bills up
to a maximum of 500% more than medical scheme tariff. CoPay
Cover could cover the medical scheme co-payments on specified
The total benefit per gap policy is R150 000 per beneficiary, per
Members must confirm the 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.
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.
Get a quote for Gap Cover: