What is Gap Cover?

How can you plan for the unplanned using a Gap Cover Product?

 

In simple terms, what is gap cover?

 

Gap cover is short-term insurance policy which provides shortfall cover where doctors and specialists charge above medical aid rates of cover. Gap cover works in conjunction with your medical aid.  We also cover “How does Gap Cover work?” for additional Gap Cover insights.

 

What are the benefits gap cover offers its members?

 

Gap cover provides the following core benefits: (Dependent on your gap cover option selected). You might also want to find out why you need Gap Cover?

 

Shortfall (Gap) cover (200% or 500% additional cover)

Covers the shortfall between what Dr charges and medical aid pays from the Risk or hospital benefit.

 

Co-Payment cover

Upfront Co-payments or deductibles Medical aid requires you as the member to pay for certain admissions or procedures.

 

Sublimit cover

Covers the difference in cost that you are responsible to pay when your medical aid pays a portion of the following medical events from a sub-limit or annual limit for Internal Prosthetics, Renal Dialysis, MRI and CT Scans and Colonoscopies or Gastroscopies.

 

Oncology cover

Covers when you have reached your annual cancer treatment limit and are liable for a portion or the full cost of your treatment subject to your policy OPL

 

Amongst these Core benefits, each option provides their own unique additional benefits.

 

What are the different gap cover packages to choose from?

 

The following Gap Cover options are available to you provided you are on a registered SA medical aid:

 

If you are on Discovery KeyCare, Discovery Essential Smart plan, Momentum Ingwe or Bonita’s Boncap, the following option will be applicable:

 

What should members be mindful of when making a gap cover claim? (typical issues you encounter when procedure isn’t followed)

 

Whenever submitting a gap cover claim, one must check the following:

 

  • If the Gap cover option you currently have provides the benefit with which you wish to claim from.
  • If the amounts the Doctor’s or Specialist’s charge as per their respective accounts are the same amounts reflecting on your medical aid statement.
  • When claiming for a shortfall, if medical aid has paid the doctor from the risk or hospital benefit
  • If the claim you wish to submit forms part of a benefit/general exclusion
  • If the Co-payment you were requested to pay came from the medical aid or directly from the Doctor (Split-Billing)
    • Split billing is a common practice used by certain doctors which are private upfront fees charged or requested from the patient.
    • These types of fees are not classified as medical aid co-payments and will not be covered by Gap cover.
    • If your Doctor requires such a fee before a procedure, request that your doctor submit the upfront fee with the full procedure bill to your medical aid and this will reflect as a shortfall (Provided that medical aid pays from the risk or hospital benefit)
  • If the Medical aid did not pay toward certain line amounts on the medical aid Statement.
    • These amounts will not be covered by Gap cover as no shortfall will be applicable
  • If you are still within waiting periods and if the claim you wish to submit is against the waiting periods applicable
  • If the claim you submitted was sent to the right email address and all required documentation are correct and updated.
Stratum Benefits (Pty) Ltd, an authorised FSP 2111, is underwritten by Constantia Insurance Company Limited, an authorised FSP 31111. Stratum Fuel Rewards is administered by YBH Rewards (Pty) Ltd, Registration Number 2018/579872/07 in association with Shell Downstream South Africa (Pty) Ltd, Registration Number 2007/016255/07. This document is a summary and does not replace any information provided in your policy documentation. In the event of any differences, your policy contract will apply. Terms and conditions apply.