In South Africa medical aid is important to securing quality healthcare. However, medical aid does not cover everything, and many South Africans are surprised by unexpected out-of-pocket expenses. This is where gap cover comes in — a vital insurance product that protects you from the financial gaps left by your medical aid. In this blog post, we will break it down and explain what gap cover is, why it is so important in South Africa, and how it can save you from substantial bills. We will share real examples and statistics to show its value.
Gap cover is a type of supplementary insurance that works alongside your medical aid. It is designed to cover the shortfall — or “gap”— between what your medical aid pays and the actual cost charged by healthcare providers for in-hospital procedures. For example, specialists like surgeons or anesthetists often charge rates higher than what medical aid schemes cover, leaving you to pay the difference. Gap cover steps in to bridge that gap, ensuring that you are not left with a big bill after a medical procedure.
Medical aid alone is not always enough to shield you from rising healthcare costs. Here is why gap cover has become a must-have in South Africa:
Medical Aid Does not Cover Everything: While medical aid offers numerous benefits, it is important to be aware of the limitations, particularly when it comes to specialist services. Even with a comprehensive medical aid plan, you might still face unexpected costs. Specialists’ fees often exceed medical aid rates and or co-payments. Co-payments are fixed amounts you are required to pay upfront for a procedure. These costs can add up quickly.
Specialist Fees Can Exceed Coverage: Even if your comprehensive medical aid plan states that it covers specialists at 100% of the Medical Scheme Rate (MSR), this does not guarantee full coverage. Many specialists charge fees that are 200% or even 300% of the MSR, leaving you to cover the difference out of pocket. For instance, if the MSR for a procedure is R1,000 and your medical aid covers R1,000, but the specialist charges R2,500, you will be responsible for the remaining R1,500. Without gap cover, these shortfalls can quickly escalate, especially for major surgeries or ongoing treatments. Gap cover is an affordable add-on that specifically covers this difference, ensuring you are protected from unexpected expenses.
Rising Out-of-Pocket Costs: Between 2016 and 2021, South Africans paid 23% more out of their own pockets, totaling over R36.7 billion in extra medical expenses. This statistic highlights how healthcare costs are climbing, making gap cover a critical safety net.
Financial Peace of Mind: It is crucial to understand the details of your medical aid plan, particularly regarding specialist coverage. If your plan only covers the MSR and you anticipate needing specialist services, gap cover can provide valuable financial protection. Without it, you might find yourself facing substantial bills that could strain your finances.
Gap cover is tailored to fill specific gaps in your medical aid coverage. Here is what it typically includes:
Important to note: Gap cover works alongside your medical aid, not as a replacement and it only provides extra cover for in-hospital procedures.. You need an active medical aid plan to benefit from it.
While gap cover is a lifesaver for in-hospital expenses, it is not a catch-all solution. Here is what it does not cover:
To highlight the importance of gap cover, consider these real-world examples of medical shortfalls faced by South Africans, backed by data from credible sources:
These figures underscore the financial risk of relying solely on medical aid, making gap cover an essential safeguard for covering these significant shortfalls.
With healthcare costs in South Africa on the rise — evidenced by the R36.7 billion in out-of-pocket expenses between 2016 and 2021 — gap cover is more important than ever. It is an affordable way to protect yourself from the shortfalls and co-payments that medical aid alone will not handle. Whether it is a major surgery or a minor procedure, gap cover ensures you are not left footing the bill.
In short, gap cover offers:
Do not wait for a medical emergency to realize the value of gap cover. Add it to your medical aid plan today and secure your financial well-being.
📞 Speak to our Medical Aid Specialist, Madelein Schoonraad
📧 medicalaid@navigatewealth.co.za | 📱 +27 63 401 9237
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