The GAP cover insurance policy is regulated under the Long Term and Short-Term Insurance Acts, not the Medical Schemes Act. It is therefore a type of medical insurance and not a type of medical aid. It is important to understand the differences between a medical aid and medical insurance, therefore you should also read the article referring to medical insurance and medical aid schemes.

GAP cover is an insurance product which aims to pay out when the medical practitioners’ costs of treating you in a hospital, day clinic or unattached operating theatre exceed the amount paid by the medical aid. Medical practitioners may all charge different rates and it is very possible that your medical aid may not cover the full cost of the medical practitioner. GAP cover does therefore not cover the hospital costs such as the ward or theatre costs. The expenses covered by the policy are referred to as benefits. There are limits to the amounts covered and the types of expenses covered (benefits). There are also many exclusions which means that in certain situations the policy will not pay out at all.

Although the cover should apply to qualifying medical related incidents occurring from the date you received the cover, there will likely be waiting periods before claims can be submitted. Also, certain pre-medical conditions may not be covered by the policy. The insurers are not compelled to cover certain illnesses or injuries unlike medical aid schemes, which are compelled to cover Prescribed Minimum Benefits (PMB)

Gap cover is considered relatively cheap and can only be obtained if you have a medical aid policy. Gap cover allows for certain dependents normally at no additional cost.

As with all insurance policies it is important that you read and understand the terms and conditions carefully, before agreeing to enter a policy.

GAP cover is not a replacement for medical aid and is a “top up” type policy. You must be on a medical aid in order to obtain GAP cover. The GAP cover is designed to provide you with limited cover for medical service providers (doctors, specialists etc…) for treatment while you are in hospital. It aims to cover those medical practitioners’ costs that the medical aid does not cover, in other words it aims to cover the co- payment you would have made to the medical practitioners. Therefore, GAP cover is only required if your medical aid is unlikely to cover the medical practitioners’ costs which may be the situation as many medical practitioners charge more than what the medical aid schemes pay out. The medical aid would be required to pay for the claims first and then only will the GAP cover be applied.

Limits
There are limits that are applied, some of which are required by regulations. The GAP cover policy may in terms of regulations only pay out a maximum of R157 000 per annum per client.

There will be many other limits applied to specific treatments. These may for example include the following:
• Limits applied to the amount of the claim which is based on the medical scheme rate. For example: 500% of medical scheme rate. Refer below for more details.
• Limits specific to the type of treatment.
• When the medical schemes have a limit for a specific treatment then the GAP policy may also apply a limit.
• There may be limits applied to the facility fee and consultation associated with admissions into the emergency room or casualty ward of a hospital.

Waiting periods
There may be a general waiting period for example three months, and there may also be a longer waiting period for specific medical conditions which may for example include:
• Head neck and spinal procedures;
• Pregnancy and Childbirth;
• Joint replacement;
• Cardiac (heart related);
• Reconstructive surgery;
• Mental health;
• Cancer;
• Pre-existing medical conditions

Exclusions (Not covered for)
There are many exclusions which may  include the following:
• Where you have not been admitted to hospital, day clinic or unattached operating theatre;
• Where the medical aid does not pay their portion of the account because you have contravened the rules of the fund;
• Where your medical aid covers some or all your account using your savings account, or you pay some or all of an account yourself because you are in a self-payment gap;
• Where the hospital charges for medication that is not part of an authorised procedure;
• Where you did not comply with your medical aid rules;
• When you chose to use a medical practitioner that is not on your medical aid schemes network;
• Certain casualty costs;
• Cosmetic procedures and treatments;
• Costs related to the treatment of obesity;
• The cost of treatment that is recoverable from another party;
• Self-inflicted injuries;
• Treatment outside of South Africa.

Prescribed Medical Benefits (PMB)
PMB’s are conditions and treatments that are required by regulation to be covered by medical aids. Most PMB conditions may be covered by the GAP cover.
Please refer to the article on PMB and medical aids for more information.

Additional benefits
Each GAP cover scheme is unique and may offer over and above the standard type cover additional limited benefits some of which may include:
• Hospital cash payment for each day in hospital in certain situations
• Benefits related to premature birth
• Death/Disability pay-outs
• In the event of death or disability contributions for a limited period towards the medical aid premiums
• Dental medical procures due to trauma or cancer
• Assistance with any Road Accident Fund claims

Each GAP cover policy may have different eligibility requirements, however the below will provide you with some general guidance.

Member of medical aid
You and your dependents must be members of the medical aid before applying for GAP cover. The insurer will require proof of this when you apply.

Financial risk assessment
The insurer is not required to assess your ability to afford the policy by completing a financial needs analysis. They may however review your credit record before agreeing to allow you to take out the policy.

Medical risk assessment
Medical insurance companies can turn you away on the grounds of your health. They can also decide to accept you, but have the right to:
• exclude benefits/cover for certain pre -medical conditions over and above the standard exclusions;
• apply a waiting period not in excess of 12 months;

You are not required to have a medical examination when applying to take out cover. You will be required to complete a medical questionnaire which will require you to disclose pre-existing medical conditions. For example, high blood pressure, diabetes or cancer.

Age
There is no entry age limit.

Dependents
The person who is a member of the GAP cover scheme in his or her own right is known as a principal member, also known as the main member. GAP cover schemes allow for the dependents of a principal member to also be covered, normally at no additional cost, and it is common for a family (parents and children) to all be on the same GAP cover plan. Children may also however join a GAP cover scheme independently from the age of 18, whereby they are the principal member.

The dependents may likely include:
• spouse or partners;
• children under the of 21 and whom are unmarried;
• children whom are aged between 21 and 25 and are a full-time student; and
• children that are mentally or physically incapacitated
If your child is a full-time student, you will be required to annually provide proof thereof to the insurance company.

More than one medical aid but one GAP cover policy
Two adults who are married may be on two separate medical aids, however they and their dependents may often be allowed to be members of the same GAP cover policy.

Most GAP cover products normally use a pay-out system based on what your medical scheme pays. This means that your medical aid will need to pay some of the hospital costs before the GAP cover will pay-out.
The GAP policies can vary substantially when it comes to working out the pay-outs. Certain policies may pay you twice what your medical scheme has paid, and others may pay up to five times. The pay-out rate is often reflected as % for example 500%. This means that the policy will pay out up to 500% of your medical aid tariff rate, subject to various limits.

It must be remembered that although the aim of GAP cover is to pay the shortfall of in-hospital medical practitioners bills, there may be many scenarios that result in the insurer not paying you out. These scenarios (exemptions) will be listed in your insurance policy and other terms and conditions set out by the insurer.

Example:
The specialist’s bill for treating you in the hospital amounts to R50 000, and your medical aid pays R10 000 and your GAP policy allows for 500% (5 times) of the medical aid payment.  Refer to the table below for the answer. A further column for illustrative purposes has been added reflecting a 200% level.  

Normally the insurer will pay you directly, however sometimes the GAP cover insurer will pay the medical practitioner directly in which case the insurer will often negotiate a small discount (example 10%) with the medical practitioner. The medical practitioner will probably be happy to offer a small discount as they are then “guaranteed” to be paid quickly as they will not need to wait for you to pay them.
It is important to submit your claims within the required time frames which may be up to three months from the date the claim was processed and paid by the medical aid scheme.
Certain GAP cover insurance companies may have an agreement with your medical aid whereby they automatically submit claims to the GAP cover company on your behalf. Check with your GAP cover company if this is the case.

GAP cover is generally not too expensive, and the premium paid by the main member allows for the dependents to be added at no additional charge.
Premiums are paid monthly and premiums for a main member below 60 during the 2019 year may be between R100 -R400 per month (2019). If you are 60 or older the amount will likely increase and may range between R300 and R700 per month (2019). The costs will depend on the policy you choose.

The premium is normally due monthly in advance, and should you not pay on time you may have a grace period of thirty days in which to make the payment in order to avoid cancellation of the policy. Should your premiums be in arrears (for example during the grace period) then your claim may not be paid.

Normally the premiums increase in January each year on renewal of the policy. The increases vary from year to year and the increases may vary between schemes.
Various factors are considered when the increase is calculated, and these include:
• the amount of financial reserves;
• the previous and expected value of claims;
• the increase in doctors and medical specialist fees;
• the change in the benefits provided to members of the scheme

Often medical related costs may be higher than inflation so keep an eye on your annual increases

Yes, you can join at any time however there will be certain matters to consider when joining a scheme which include:
• All benefits/cover you will receive will not be pro-rated;
• You may have waiting period before you can make certain claims;
• You may have specific medical exclusions

Cancelation
The medical insurance company may terminate the policy by giving you written notice at any time. Normally they will provide you with two months written notice. Be sure to understand when the benefits cease if this happens.

Changes to the policy terms
The insurer may change the terms of the policy at any time provided they give you written notice thereof. They may, for example be required to provide you with two months written notice. Should you be unhappy with the changes you can always terminate the policy.

You will likely be able to cancel the policy at any time provided you provide the insurer with at least one month’s written notice. Be sure to understand when the benefits cease before you provide the written notice.
All insured events (claims) that occurred before terminations should be covered provided you submit the claim within the required time frames set out in the policy which could be within two months of the medical aid pay-out.

Yes, you may have all three, however many people may choose some sort of combination, for example having a medical aid plus a hospital insurance plan. It is best to read the articles on each option to better understand the differences of each option.
If for example you are on an expensive comprehensive medical aid you may not need GAP cover. Always try and consult a qualified independent advisor before making a decision.

If you travel abroad and incur medical costs you will not likely be covered by the GAP policy. Check your policy details before travelling.

Certain groups (such as Discovery) that offer medical aid schemes also offer GAP cover.
There are many insurers that provide GAP cover and an independent financial advisor would be well be able to guide you when deciding which company and product to use.

Your requirements
First consider your ideal requirement and risks. Consider your and your family lifestyle, and life stage. You may for example wish to have children soon.

Affordability
Also consider what you can afford If you have not yet prepared a personal budget, you can use the handy template available on this website. By preparing the budget you will be able to determine what you can afford.

Do it yourself
Should you wish to assess the various options yourself, you could assess the various plans offered by the various companies. This would entail comparing the benefits and costs of the various plans. You could then approach the insurance company of your choice directly.
There are various online platforms that can assist you in getting quotes from various companies.

Use an advisor
Should you prefer to use an independent advisor, you could approach one and ask them to assist you in the process of selecting the right product. Please read the article regarding independent advisors on this website to help you consider the benefits and costs of this option. You will find the contact details of an independent advisor on this website.

Changing insurance plans (Staying with the same insurance company)
Policy holders may decide to change GAP plans, if there is more than one offered by the insurance company, (stay with the same insurer), however the insurer may only allow the change if it is done so at the annual renewal date which is normally 01 January. You could however be subject to waiting periods which apply to the new plan.

Changing insurance companies
You can choose to change GAP insurance companies at any time. You will need to provide the current insurer with sufficient notice as set out in the insurance policy document.
The best time to change from one company to another is likely to be 01 January as the insurers generally renew their polices at this date, however certain insurers may have different annual renewal dates. You should take advice on when and how to change companies to best minimise the waiting periods. You should start to investigate options many months before changing.

No, there are no tax rebates. There is a tax benefit available to those contributing towards to medical aid schemes. Refer to the article regarding medical aid schemes for more information.

No, the amounts received are not taxable, however be sure to keep all the relevant paperwork regarding the amounts received as the South African Revenue Service (SARS) may one day wish to audit you and you will then need to prove to SARS where the funds were received from and why they were not declared as taxable income.

If you believe that the GAP scheme is not paying out what it should, you should obtain clarity from the insurer as to the reasons therefore and then consider one of the options below:
• obtain assistance from the person/company that manages your relationship with the insurance company if applicable -being your medical aid scheme consultant/agent or your independent financial planner;
• approach a lawyer with the required expertise to assist you, however this could be costly;
• approach the Ombudsman , within a period of six months. The FAIS Ombud may be contacted as follows:
Tel: 012 470 9080
www.faisombud.co.za