What is Gap Cover?

GAP Cover is a product that was designed to cover the principal member and dependents (of a medical aid scheme) for out-of-pocket expenses that result from your medical aid paying less than you are being charged, by service providers, for an in-hospital procedure. In recent years this has become more prevalent as more and more medical practitioners are charging more than the benefits offered by the medical scheme.

The problem, simplistically, is that the medical aid industry, as a general rule, base their scale of benefits on their medical scheme benefit rates and medical aids apply benefits to their members based on these rates - however service providers (surgeons, anesthetists etc.) are not bound to observe these guidelines, causing a “gap” between what is charged and what the medical aid reimburses. This problem is highlighted by the following analysis of an actual claim:

Medical Gap Cover - Personal - TD Adminstrative Services  Effective January 2023 – if you are under 65 at the time you apply for the cover, Gap and Gap Plus cover costs only R331.00 per family per month.
Group and senior rates are available on request

Spinal Fusion
Description Charged Medical Aid Benefit Gap / Gap Plus Cover Benefit
Neurosurgeon R 44 307.00 R 23 572.20 R 20 734.80
Anaesthetist - Pre op Exam R 981.80 R 705.20 R 276.60
Anaesthetist - theatre time R 26 155.60 R 19 532.30 R 6 473.30
Hospital co-payment R 16 350.00 Nil R 16 350.00
Total     R43 834.70

The Gap cover would pay out the difference between the service providers charges and the medical aid refund, to a maximum of three times the medical scheme benefit rate and would pay the hospital copayment of R16 350.00 if the “gap plus” cover had been selected.

Extended Benefit - Gap Plus

Most medical schemes now expect their members to pay a co-payment on admission to hospital. The Gap Policy has been extended to include this.