Should I get Gap cover?

THE days when medical schemes paid the full cost of surgeries in private hospitals are gone forever.

Being covered by your medical aid at 100% of the medical scheme rate does not mean you are covered in full.

The purpose of gap insurance is as the name implies. It covers the gap shortages that arise between the rates charged by medical practitioners for in-hospital and out-of-hospital treatments and the rates paid by medical schemes.

Medical practitioner fees are unregulated, and many times, medical specialists do not charge scheme rates which means your medical aid will only pay a portion of the outstanding amount.

Gap cover has never been more relevant than now. Many people are downgrading their medical aid plans due to financial constraints which in turn lowers their cover. If you downgrade your medical aid, it is vital that you get additional cover to ensure that you do not get surprised with a massive medical bill.

Private healthcare is becoming more and more expensive. Although private healthcare facilities have increased significantly in recent years, hospitals are fuller than ever before. As the demand for good quality healthcare increases, the rates of service providers increase dramatically. There is also a great shortage of certain medical specialists who have left the country and moved to countries such as Australia and Canada.

Furthermore, more expensive medical equipment and new technology also contribute to an increase in medical costs.

The continuous improvement of medical care and new treatment options for diseases such as cancer and heart diseases along with improved medication, surgical procedures and technology are contributing to higher costs.

New technologies that offer better successes and fewer side effects are more expensive than older treatment options. Therefore, shortfalls for medical expenses may increase and medical schemes may need to regularly adjust the annual limits and compulsory co-payments for certain medical procedures that may put scheme members under greater pressure.

For these reasons, the supplementary coverage of gap insurance is a necessity to strengthen the options of medical schemes. Gap cover provides peace of mind to medical scheme members because they can afford the services of the best – and usually the most expensive – specialists or surgeons without any worries about account shortfalls that medical schemes do not cover.

In addition, it provides cover for unforeseen upfront payments imposes by schemes – some co-payments for scans are more than R4 000 – and supplementary cover for cancer treatment and sublimit shortfalls for prostheses that are mostly used in joint replacements and heart surgeries.

The monthly premiums for a medical scheme are expensive and increase annually. When compared to the premiums of gap cover and the additional benefits it offers, the value of such a policy is surely the best investment in piece of mind and good health care.

With monthly premiums starting at as little as R270 per family, gap insurance is affordable. Most coverage options are designed to meet everyone’s needs and serve as a benefit enhancer for scheme members who downgrade to cheaper options.

Due to current economic conditions, the downgrade to cheaper scheme options may help reduce monthly costs with expenses. Sometimes members are on more expensive options with benefits they do not use, and an option downgrade will be to their advantage. Although downgrades to cheaper options have an impact on schemes’ pay-out rates that could potentially cause gap deficits, strengthening an affordable gap policy is sufficient to prevent it.

Gap cover offers much more than just coverage for in-hospital procedures. Most gap options also offer benefits for out-of-hospital medical costs such as emergency care at an emergency unit, MRI and CT scans, oncology treatments, trauma counselling, screening tests and specialists consultation visits to name a few.

It is important to check the variety of gap options carefully as some differ from each other, and the benefits are not the same.