Gap Cover

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Don’t worry, be happy… I do have a medical aid, don’t I?

Nowadays the Gap and Cap Cover are buzz words. Yet, few people really take notice of it, because, as they say, I do have a medical aid, don’t I?

Sadly, most people will only realise what Gap cover is all about when it is too late. When you find yourself in hospital before an operation and it only dawns on you then that your medical aid is not going to pay the full account, it is too late in the day to wakeup. You will have to fork out the shortfall (which can run into the thousands) yourself.


Not so many years ago, specialists, doctors and anaesthetists could base their fees on two tariff scales, namely contracted-in or contracted-out. Contracted-in tariffs were also known as scheme-tariffs or RAMS-tariffs. Contracted-out tariffs were also known as private tariffs or SAMA-tariffs.

These tariff-scales are unfortunately not obligatory anymore. Each scheme may accordingly now use its own tariff scale on the one hand and on the other, a service provider may charge you in principle whatever he or she wants.

What is the Gap?

The Gap is the difference between the account furnished by the doctor, specialist or anaesthetist and the amount which your scheme option will pay towards the account according to its own tariff scale.

Let’s say the scheme tariff for a certain surgical procedure amounts to R5 000 but your surgeon charges R 8 000; then the ensuing difference of R3 000 is the Gap.

Gravity of the problem

It can easily happen that the Gap is so great that you will have to pay more for the specialist than what your scheme has paid him or her. You will have only yourself to blame for not taking out Gap cover in time.

A few years ago a client of mine underwent a big operation. The surgeon charged him R30 000 (amounts rounded off) which were 3X the scheme tariff of R10 000. He did not believe in Gap cover and refused to take it out. So, he had to pay the Gap of R20 000 himself. He was grumpy and fuming, but as always it is no use crying over spilt milk.

In contrast, someone else would have had to pay R89 665,01 from his own pocket if it was not for the supplementary cover he took out a few months before the day his life changed unexpectedly and dramatically due to the onset of a very serious illness.

Three major operations, extreme complications due to his diabetes,  six weeks in intensive care, a further lengthy stay in hospital…

What will your financial situation be if this happens to you? Will your family be able to also insist on you being treated in the best hospital and by the specialists of their choice, regardless the costs involved?

Other  ways to address the problem

Schemes try to solve the problem by contracting with so-called network doctors that will charge you according to the scheme’s tariff. This is basically confirmation of the reality of the need to avoid or provide for possible shortfalls. The downside with this plan is that you have no guarantee that the specialist of your choice will be on the scheme’s network.

Perhaps one could argue that you only need to find a specialist who will work according to scheme tariffs and then you need not worry about the Gap. This might be a solution, IF you could indeed find such a specialist. Fewer and fewer specialists are prepared to work according to scheme tariffs and it is not so easy to find one who does.

The real problem though is when you really want to make use of a specific specialist which you trust unreservedly and have put your faith in. What will you do if he/she is not prepared to charge you scheme tariffs?

Well, you will either have to make use of the second best (even if it is only second best because of your perception) or you will have to take out a second bond on your house to pay the specialist of your choice.

The importance of Gap Cover

Some of the big insurance companies have now also brought out Gap cover products during the past year or so. They would not have done so if they did not recognize the massive need and importance of Gap cover.

The Gap cover which some of the more expensive options still offer, also admits to the need and importance thereof. Nevertheless, I recommend that you take out further supplementary Gap cover on top of this. Rather make sure you are on the safe side. The 200% or 300% Gap cover these options offer is totally inadequate.

The total number of Gap cover claims and the Rand value thereof (millions!) have increased tremendously over the past five years. Again confirming the importance of Gap cover.

How to protect yourself and your loved ones

There is no doubt that a trustworthy medical scheme together with effective Gap and other supplementary cover offer the best protection against the shockingly high costs of proper health care

(You can take out Gap cover only if you are also a member of a medical scheme. It is not a replacement of a medical scheme, it is an addition thereto. Gap cover is mostly to do with in-hospital services, but do cover some situations out of hospital, e.g. cancer treatment.)

It gives peace of mind to know you have satisfactory Gap cover, no matter what your scheme is prepared to pay. To know you can consult and afford any specialist of your own choice in hospital. To know you are not bound to a network doctor or specialist. To know you are responsibly looking after yourself and especially your loved ones.

Gap cover is uncomplicated and affordable. Why not take it out today?

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