WHAT IS GAP COVER?
It’s a short-term insurance policy mainly designed to cover the tariff shortfalls when doctors and specialists charge private fees that your medical aid doesn’t fully cover. For Gap Cover to work, you must be a member of a registered South African medical aid regulated by the Council for Medical Schemes.
Have you noticed that we said “mainly”? Gap Cover offers so much more than just covering tariff shortfalls.
If you think Gap Cover is just another insurance policy, think again.
WHY GAP COVER?
With Stratum Benefits Gap Cover, you get an affordable insurance policy that gives you peace of mind, knowing that your medical expense shortfalls are covered.
Food for thought…
As insurance policies go, we, too, have waiting periods and benefit exclusions, but in many instances, this insurance policy pays out more in benefits than you’ll ever pay in premiums.
Medical aid pays healthcare and service providers’ accounts up to a specific rate varying from 100% to 200% or 300%, depending on your medical aid plan.
If your specialist is contracted to your medical aid, you shouldn’t have any shortfalls because your medical aid will pay your specialist at the agreed-upon rate. But suppose your specialist isn’t contracted to your medical aid. In that case, they’ll probably charge private fees, and you’ll be responsible for paying the difference after your medical aid has settled a portion. How’s that working out for you?
Let’s say your specialist charges R 15 000 for a medical procedure, and your medical aid pays R 14 000. You’ll be left with R 1 000 to pay out of your pocket. That’s not too bad. Perhaps R 1 000 here and there isn’t anything to lose sleep over, but what happens if your medical aid only pays R 5 000 of the R 15 000 medical procedure?
Here’s a scenario…
You go for joint replacement surgery.
You’re on a 100% medical aid plan.
The hospital is fully covered because they charge agreed rates covered by your medical aid. Phew!
However, the orthopaedic surgeon charges 400% above the medical aid rate, and the anaesthetist charges 300% above the medical aid rate. This means the surgeon charges four times more than your medical aid plan’s rate and the anaesthetist three times more.
| Total cost of surgery | Medical aid pays 100% of your medical aid plan’s rate | What you’ll be liable for without Stratum Benefits Gap Cover | |
| Orthopaedic Surgeon | R 24 000.00 (Charged at 400% above medical aid rate) | R 4 800.00 | R 19 200.00 |
| Anaesthetist | R 6 000.00 (Charged at 300% above medical aid rate) | R 1 500.00 | R 4 500.00 |
| Total | R 30 000.00 | R 6 300.00 | R 23 700.00 |
| Orthopeadic Surgeon | |
| Total cost of surgery | R 24 000.00 (Charged at 400% above medical aid rate) |
| Medical aid pays 100% of your medical aid plan’s rate | R 4 800.00 |
| What you’ll be liable for without Stratum Benefits Gap Cover | R 19 200.00 |
| Anaesthetist | |
| Total cost of surgery | R 6 000.00 (Charged at 300% above medical aid rate) |
| Medical aid pays 100% of your medical aid plan’s rate | R 1 500.00 |
| What you’ll be liable for without Stratum Benefits Gap Cover | R 4 500.00 |
| Total | |
| Total cost of surgery | R 30 000.00 |
| Medical aid pays 100% of your medical aid plan’s rate | R 6 300.00 |
| What you’ll be liable for without Stratum Benefits Gap Cover | R 23 700.00 |
It’s not uncommon for surgeons and anaesthetists to charge more than the medical aid rate, but can you afford the private fees not fully covered by your medical aid?
Being covered by the best-suited Gap Cover option that works with your medical aid plan means you don’t have to dip into your savings to pay outstanding medical bills.
We offer Gap Cover options that provide cover at an additional 300%, 400% or 500% above what your medical aid pays.
UPFRONT CO-PAYMENTS AND OTHER MEDICAL EXPENSES
Did you have to pay an upfront co-payment before being admitted for joint replacement surgery? Co-payments will be deducted from available funds in your medical savings account or paid out of pocket.
Our Co-Payment Benefit refunds co-payments imposed by medical aids.
Was the internal prosthetic device you needed for your joint replacement surgery fully covered? Our Sub-Limit Benefit covers the difference between what your medical aid pays and the cost of an internal prosthetic device.
Was the follow-up visit with your specialist fully covered? Our Out-Patient Specialist Consultation Benefit can assist with the shortfalls.
We’ve only touched on three benefits, but there’s so much more to Gap Cover.
We beg to differ if you still think Gap Cover is a nice-to-have policy. Given the rising cost of private healthcare, the amount we pay out in claims, and the increase in the frequency of claims per policy, it’s a must-have.
