Gap cover

SeRpEnT

Expert Member
Joined
Feb 15, 2008
Messages
4,488
What gap cover do you have and price? Have you been informed of the 2019 increase yet?

My gap cover (Admed by Guardrisk) has increased by 20% (!!) to R189 p/m.
Needless to say I'm a bit pissed off at such a big increase.
 

craiglotter

Well-Known Member
Joined
Jul 11, 2014
Messages
257
I pay R358 per month for Gap Cover from Stratum. (This is against my Discovery Coastal Core medical aid which covers myself, wife, and two minor girls. Discovery rings in at R4102 per month. I don't have Vitality bolted on).
 

TheSlinger

Senior Member
Joined
Jun 6, 2014
Messages
843
I pay R366 (total) for Zest Life, with Profmed medical aid - ProActice (Savy). This is for the Missus and I.
 

saor

Honorary Master
Joined
Feb 3, 2012
Messages
21,828
Trying to recall the other thread where people were saying gap cover is the biggest scam since whatever...
 

Fulcrum29

Honorary Master
Joined
Jun 25, 2010
Messages
31,928
Trying to recall the other thread where people were saying gap cover is the biggest scam since whatever...
From my experience with the medical industry… when the ‘service provider’ associate you with a medical aid or and gap, they slap those coverages straight on the bill by method of price inflation. If the medical aid or gap refuse to pay out the ‘full’ total of those substantial amounts… you know.

They finger your pie good.
 

Mike Hoxbig

Honorary Master
Joined
Apr 25, 2010
Messages
35,473
From my experience with the medical industry… when the ‘service provider’ associate you with a medical aid or and gap, they slap those coverages straight on the bill by method of price inflation. If the medical aid or gap refuse to pay out the ‘full’ total of those substantial amounts… you know.

They finger your pie good.
They don't need to know that you have gap, only medical aid...
 

Fulcrum29

Honorary Master
Joined
Jun 25, 2010
Messages
31,928
Admed is atrocious, they make it hard to submit claims with them. They, in my case, have always stretched out the process. They request this and that, which is standard procedure, but when you give them this and that they seem to want more or they want it like this and not that. They make the window so small that it is unbearable to work with them.

Also, they are very strict on what they, gap, cover. This is hardly the purpose as to why gap cover exists, thanks to ‘pre-existing’ conditions.

Best to go with Sanlam, ABSA or that mentioned by TheSlinger.
 

PsYTraNc3

Expert Member
Joined
Jan 4, 2012
Messages
3,171
Just over R400 with Zest Life (Bonitas medical aid) for myself and the wife.
Paying way too much but don't want to change anything now with a little one on the way.
 

Cius

Executive Member
Joined
Jan 20, 2009
Messages
5,958
We switched from admedgap to african guardrisk or something like that. Its about R200 to cover my family.
 

Fulcrum29

Honorary Master
Joined
Jun 25, 2010
Messages
31,928
They don't need to know that you have gap, only medical aid...
I know this, but giving the medical industry the slightest notion that you have medical coverage gives them an extreme hardon to open their ‘medical aid/gap’ price book to tier your bill accordingly. It is unethical. It is like an internal pyramid scheme. My reply was on the ‘scam’ remark.
 

SirFooK'nG

Executive Member
Joined
Feb 13, 2009
Messages
8,027
Didn't have any, just had to fork out R8K shortfall on a procedure. My ENT is 400% over the Discovery Rate, My plan covers up to 200% :crying:...

Never again I tell you! I just completed my forms for Turnberry Gap Cover (R382 p/m)... We get a company discount off that figure tho, so that helps a wee bit.
 

Dairyfarmer

Expert Member
Joined
Apr 17, 2016
Messages
3,676
R150-R200 per person may seem like a lot until you need it. And I promise you, you will not be sorry.

Oh and btw, the medical expenses that are covered by gap, you can still add the amount to your tax return and get some tax back. Usually you medical aid will report them as uncovered expense on your tax certificate.
 

Fulcrum29

Honorary Master
Joined
Jun 25, 2010
Messages
31,928
Two articles on GAP in SA:

https://www.health24.com/Medical-schemes/General-info/looking-for-medical-aid-gap-cover-these-are-the-top-options-20180601

Looking for medical aid gap cover?
These are the top options

Are you looking for gap cover? A recent survey revealed the top gap cover providers in South Africa, making it easier to choose one.

Top providers

Sanlam and Absa emerged as the top-ranked gap cover providers in South Africa.

Sanlam offers the best value for money to people under the age of 60 – their Comprehensive Gap Cover costs approximately R250* per month per individual or family.

While for individuals (or families) older than 60 years of age, Absa came in top – their Gold Plan costs approximately R435* per month.

Both plans offer comprehensive cover – gap, co-payment, oncology and sub-limit in the 500% sector.

They used these four core benefits to rate the various plans:

  • Gap cover: in-hospital gap cover and percentage cover the scheme provides (weighted 60%)
  • Co-payment benefit: the provision of a co-payment benefit (weighted 13.3%)
  • Oncology cover: the provision of additional cover for cancer (weighted 13.3%)
  • Sub-limit benefit extender: provided to enhance sub-limits imposed by medical aids (weighted 13.3%)
In addition, plans were grouped into sectors based on the level of cover offered: 200%, 300%, 350% or 500%+.

“The most popular type of plan, according to the survey, is one which offers in-hospital gap cover, co-payment, oncology and sub-limit, to the level of 500% +,” says Jill Larkan, head of Healthcare Consulting and Thought Leadership at GTC.

“These plans offer cover to approximately 550 000 families, representing a small portion of the potential medical aid market which has in excess of eight million members.”

Here are other companies that did well, based on the highest core ratings and premiums:

Top 6 best core performers’ premiums, under 65s, individuals and families

1. Sanlam Comprehensive Gap Cover – R250 (R600 for over 60s)
2. Absa Gold – R315
3. Zestlife Universal – R327 per individual under 55 (R413 over 55s); R413 per family
4. KaeloXeulus Fusion – R350
5. Ambedown Gap Select – R390
6. Ambedown Gap Supreme – R420

Top 6 best core performers’ premiums, over 65s, individuals and families

1. Absa Gold – R435
2. Zestlife Universal – R470
3. Ambedown Gap Select – R585
4. KaeloXeulus Fusion – R600
5. Sanlam Comprehensive Gap Cover – R600
6. Ambledown Gap Supreme – not available to over 65s
https://www.fin24.com/Money/Health/what-gap-cover-will-and-wont-pay-for-20170330

What gap cover will and won’t pay for
Although gap cover is generally not expensive (and you can only take it out if you/your family already are a member of a medical scheme), it might be an idea to go and read the fine print.

Warning: you might not like what you find there, as gap cover insurers have found themselves in the firing line of spiralling private healthcare costs and have had to rein in their expenditure to remain financially viable. Unlike medical schemes, insurance companies are run for profit.

Gap cover usually requires only one policy for a single member/any dependants, so it is still a very good deal if you have several dependants. In essence you actually just pay once, and you are all covered, provided you and your dependants are all on the same scheme and on the same option.

It must be remembered that gap cover is an insurance product, and does not resort under the regulations of the Medical Schemes Act of 1998, but under the regulations of the Short-term and Long-term Insurance Acts.

...

So how are gap cover payments calculated?

Gap cover used to pay the difference between what your scheme paid, and what the bill was for private doctors and specialists in-hospital. In practical terms, this meant that even if you had the cheapest hospital plan which only paid a fraction of the costs, you would be covered in full.

In a circular sent out to its members at the end of 2016, Guardrisk mentions that during the last three years, the responsibility of payment of the largest share of medical practitioners’ costs has shifted from the medical schemes to the gap cover providers. In certain cases, the gap provider has carried up to 80% of the costs, leading to a severe increase in the cost of medical practitioner shortfall claims each year.

Automatic full payment of any shortfalls is not sustainable in the long run, according to the Guardrisk circular, and many gap cover products have introduced a new way of calculating how much of the co-payment they will cover. What many of them have switched to is a payout system based on what your medical scheme pays.

Some will pay up to twice what your medical scheme has paid, and others up to five times in a kind of match-pay system, depending on the kind of policy you have.

In practice, what it amounts to is the following: if your bill from a private practitioner is R25 000, of which your medical scheme has covered R7 000, your gap cover (if it pays twice the medical scheme contribution), will pay R7 000 x 2, which is R14 000. So your bill would work out as follows

Doctor’s bill: R25 000

Minus medical scheme contribution: R7 000

Minus gap cover contribution R14 000

The shortfall (for your own account) R4 000

If your scheme paid R10 000 of the above bill, your gap cover would pay twice that (namely R20 000), but as the total bill or maximum amount is only R25 000, that would be more than the total. The difference is not paid out to you, but the whole amount of the bill of R25 000 would be covered between your medical scheme and your gap cover policy. It is to your advantage then to have a medical scheme that pays out more than 100% of the medical scheme tariff.

It must be remembered that the purpose of gap cover is to pay the shortfall of private doctors’ in-hospital bills. There are many things that most gap cover policies will not pay for. You need to look at the small print in your policy documents.

Things most gap cover policies won’t pay for
  • Ward costs in a hospital or step-down facility;
  • Upgrades to a private room;
  • Pre-admission consultation costs;
  • Medication (both in-hospital and take-home);
  • External prostheses (an artificial breast or a prosthetic leg);
  • External appliances, such as wheelchairs or crutches;
  • Routine medical examinations, such as ultrasounds;
  • Home or private nursing;
  • Extra costs related to weight/BMI-related procedures;
  • Mental health disorders, transportation costs (such as in an ambulance);
  • Out-of-hospital dental treatments;
  • Cosmetic procedures;
  • Costs incurred for treatment by a non-designated service provider (determined by your medical scheme); and
  • Co-payments for any procedure for which you are in a waiting period.
Some pleasant surprises in what gap cover might pay for

Again, this depends solely on your insurance provider and the policy you have chosen (there is usually a choice between two: the no-frills version and the more comprehensive one). It can do no harm to check and even if the amount is not huge, every little bit helps. You might find that your gap cover could pay for some of the following:
  • Some out-of-hospital procedures that used to be require hospitalisation, but can now be performed in a doctor’s surgery. Contact your insurer for details on these.
  • Co-payments for certain specified hospital procedures (in full). Call your insurer for details.
  • A contribution to cancer treatment costs once your cancer benefit on your medical scheme has run out.
  • The shortfall on internal prostheses (such as a hip replacement procedure) up to a stipulated maximum.
  • A lump sum for first-time cancer diagnosis (terms and conditions usually apply).
  • Lump sum benefit for accidental death or permanent total disability.
  • Lump sum for long-term hospitalisation over a certain period of time.
  • Tooth repairs in the case of accidental injury (such as breaking a tooth in a car accident).
  • Some casualty costs (once again, terms and conditions apply).
 
Top