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Opt for gap cover to cover shortfalls

Typically the most common medical expense shortfalls relate to hospital admissions.

In these instances the member may have to pay the difference between what their specialist charged and what their scheme paid for their inhospital treatment, or for consultations and treatment in the period prior to and after the admission, according to Deon Kotze, head of Research and Development at Discovery Health, the administrator of Discovery Health Medical Scheme.


Gap cover covers these shortfalls, up to a defined limit. Critically, gap cover is not a medical scheme product but is an insurance policy that is sold separately from medical schemes, which provides the policyholder and their family with defined cover for medical expenses not covered in full by their medical scheme.

“Gap cover is appropriate for members who are concerned about their exposure to these shortfalls and want the option to consult with specialists who charge more than medical scheme rates,” says Kotze.

To purchase gap cover, individuals need to have medical aid cover. However, points out independent financial advisor Dawn Ridler, the industry is still in a fair amount of turmoil following regulatory intervention. “Regulators don’t like short-term insurers pretending to be medical aids, and not providing prescribed minimum benefits,” she says.

Ridler advises choosing a provider that has been providing gap cover for several years.’“Make doesn t expire sure when the you cover reach age 65, even if this means you have to pay a higher premium. Look for cover that will pay up to 500% of specialist fees as well as any co-payments you are required to pay.”

Read the small print, she says. “And don’t disclose the fact you have gap cover to your medical provider. Rather leave this section of any form blank or risk having your fee loaded.”