What is Gap Cover?

Gap Cover is a short term insurance product for members of a medical scheme, providing extra cover for medical shortfalls that could occur during in-hospital procedures.

Your medical scheme option might provide you with cover of 100%, 150% or 200% of the medical scheme tariff, but medical service providers can charge up to 500% of that tariff, creating a shortfall amount which would be an out of pocket expense for you.

If you are a policy holder of Gap Cover, the difference between what your medical scheme would pay and the actual cost of the doctor’s private rate could be covered up to 500%.

Why should you get Gap Cover

  • It’s an affordable and easily accessible way to avoid medical shortfall amounts which often occur during in-hospital procedures.

Who qualifies for Gap Cover

  • The policy covers the principal member, spouse or life partner and biological or legally adopted children that are registered as such on his/her medical scheme certificate.
  • Dependants must be registered on the policy as well to enjoy cover.

How and when will Gap Cover apply?

  • Gap Cover is for associated services rendered in a hospital, unattached operating theatre or day-clinic. Gastroscopies and Colonoscopies performed in the GP or Specialist’s rooms are covered up to 500% of the Medical Scheme Tariff, limited to 2 scopes per beneficiary per annum.
  • A successful Gap Cover claim will be paid directly to the principal member of a registered medical scheme.
  • The claim will be paid if no underwriting applies and if the client is not subject to exclusions as per the policy contract
  • When becoming a Gap Cover policy holder, the client must familiarise themselves with their schemes’ limitations and exclusions, as Gap Cover cannot cover costs that occur due to your medical scheme’s excluded benefits. (i.e. if your medical scheme does not pay for a procedure, then Gap Cover cannot grant benefits.)

What does it cost?

  • Gap Cover is available at only R160 per family, per month
  • CoPay Cover is also available at R70 per month per family (R12 000 limit per event)
  • Or, get Gap Cover and CoPay combined at only R215 per family, per month