Do we Really Need to Cough up for Gap Cover?


We all know the importance of Medical Aid and, therefore, many of us are on some sort of medical plan. This presumably means that we are covered for any eventuality, right? Wrong! We see a trend of individuals not giving their Medical Aid a second thought and wrongfully assuming that it covers everything when a medical event occurs. If this was the case, why does Gap Cover exist? Before considering whether you need Gap Cover if a Medical Aid is already in place, you first need to know what Gap Cover is.


What is Gap Cover?


Gap cover essentially is a type of top-up insurance for Medical Aid- paying for extra medical expenses that your Medical Aid plan would otherwise not cover.


How does it work?

Whichever Medical Aid service provider you are with, they set an annual medical aid rate. This is the base rate that registered medical professionals can charge for any medical procedures or treatments. Most Medical Aids will cover up to a particular percentage of the rate charged by the medical professionals – this amount is generally up to 300% of this rate. But, medical professionals are able to charge whatever they wish for their services, which is usually more than the base rate that your Medical Aid agrees to pay. In this scenario, you are responsible for paying for the shortfall.

For example, let’s say that your Medical Aid covers 300% of the medical aid rate for surgery. However, if your surgeon charges 400%, you will be responsible for covering the remaining 100%. Medical treatments and procedures can be extremely costly, which means that you can get an almost instant bill for tens of thousands of Rands.


What is not covered?


Now that we have established that Gap Cover is additional insurance that you purchase in conjunction with your Medical Aid to cover the shortfall of medical procedures, the question is, what does it not cover? Every Gap Cover Service Provider and policy is different, and it is important that your financial advisor informs you about the fine print and exclusions of your individual policy. Here are a few general exclusions that most Gap Cover service providers will not pay for:

· Routine medical examinations (i.e., ultrasounds)

· External prostheses (i.e., prosthetic leg) and appliances (i.e., crutches or wheelchairs)

· Home or private nurses

· Additional costs or procedures related to weight/BMI

· Cosmetic procedures

· Out-of-hospital dental treatment

· Mental health disorders

· Transportation costs (i.e., ambulance)

· Ward costs in hospital or step-down facility

· Upgrades to private rooms

· Pre-admission consultation costs

· Medication (both in-hospital and take-home)

· Costs incurred for treatment by a non-designated service provider

· Co-payments for any procedure for which you are in a waiting period


What is important to understand is that Gap Cover will not cover something that your Medical Aid excludes.


What is the verdict? Is Gap Cover worth it?


The answer is, without a doubt, YES. If you have Medical Aid, you should also have Gap Cover to accompany it. Medical procedures can be expensive enough to lead to potentially crippling debt if you don’t have comprehensive cover in place. Gap cover is a relatively cheap way to safeguard you from life-changing debt resulting from Medical Aid shortfalls. PBA Financial Services can help you with dependable and affordable Gap Cover with great benefits and comprehensive cover. Contact us today and get a quote.


Contact us:

Phone: 011 803 9686

Email: vivian@pbafsa.co.za or bev@pbafsa.co.za

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