Frequently Asked Questions
What is Gap Cover?
Gap Cover is NOT a Medical Scheme or an alternative to a Medical Scheme. It is a Short-Term Insurance product that is designed to accompany and compliment your Medical Scheme. The main purpose of Gap Cover is to pay the shortfall on the Specialist & Anaesthetists accounts for a procedure performed in Hospital or at Day Clinic.
What is a shortfall on an account and why do I need Gap Cover?
An example of this would be the following: You have a shoulder operation and your Medical Scheme only pays normal Medical Scheme tariffs/rates (100%) to the specialist. In this instance, the amount of R3 450. The specialist however charges 300% (R10 350), which means that you would have to pay the difference (R6 900).
Do I have to be a member of a Medical Scheme to join Gap Cover?
Yes, you have to be a member of a registered South African Medical Scheme.
Does Gap Cover pay out of Hospital expenses eg (GP’s, Acute?rather use Chronic? Medication, Optometry etc.)?
No, Gap Cover does not cover out of Hospital (day-to-day) expenses.
What other benefits are included in my Gap Cover policy?
This would depend on what Gap Cover product you decide to join, but it can include the following:
- Co-payments (upfront co-payments on specific medical procedures can be claimed back from Gap Cover)
- Emergency Ward Treatment – Cost incurred for physical injury caused by an external force.*
- Prosthesis benefit – If prosthesis used exceeds benefit limit on Medical Scheme – you claim the balance.*
- Oncology benefit – Claim 20% co-payment when Oncology benefit on Medical Scheme is exhausted.*
- Medical Scheme Premium Waiver – Medical Scheme monthly premiums paid for specific time period.*
* Please note that these benefits have Rand limits attached to them.
Who can be covered under my Gap Cover policy?
This differs depending on which Gap Cover you have joined. Some Gap Cover products will allow you and your Spouse to be on different Medical Schemes, but still, be on one Gap Cover. Other Gap Cover products won’t. Most Gap Cover products cover the whole family, as long as you are all on a Medical Scheme. Full-time students or child dependants can also remain on the Gap Cover as long as they are dependants on their parent’s Medical Scheme. This is also only allowed up to a certain age, then they would have to join their own Gap Cover policy. Some Gap Cover products also allow Adult Dependants (Grandparents, Uncle’s, Aunts, etc.) to join under the same Gap Cover policy under the main member, as long as they are dependants under the main members Medical Scheme.
What is the maximum age at which an individual can apply for Gap Cover?
This differs from product to product, but it is usually 65 or 70 years of age.
Does my Gap Cover policy get cancelled when I turn 65 or 70?
No, it does not.
Is the monthly premium included in my Medical Scheme premium?
Unfortunately not, because it is a totally separate product and as mentioned is a Short-Term Insurance product.
Is my Gap Cover policy linked to my specific Medical Scheme?
No, as it is a “stand alone” product. If you ever change Medical Scheme’s, it will just continue.
What documents do I need to complete in order submit a claim?
To claim from Gap Cover, you will need the following documents:
- Completed claim form.
- Copies of the accounts you are claiming for.
- Proof of payment for the co-payment on the procedure performed. (if applicable)
- Copy of the Hospital account – you will have to call the Hospital and request that they e-mail you a copy.
- Medical Scheme Statement – reflecting the amount they have paid to the service provider.
Does Gap Cover pay the service provider directly?
No, they pay the member and you need to pay the service provider. PLEASE NOTE: Gap Cover does not pay money into a Third Parties account, so please make sure that the bank details provided on the claim form is correct and that it is the main member’s banking details.
Are planned PMB procedure’s claims covered?
According to the Medical Schemes Act, your medical scheme needs to pay PMBs in full and at cost. If you have made use of your Medical Schemes (DSP – Designated Service Provider), you should not have a problem. There are however Gap Cover policies that do cover PMB procedures.
What are the underwriting / waiting periods when joining?
The standard underwriting / waiting periods on joining are as follows:
- 3 Month general waiting period.
- 12 Month Condition Specific waiting period on any planned procedures and pre-existing conditions.
- 12 or 10 Month waiting period on maternity / pregnancy.