GAP cover – the medical aid accessory option
Every medical aid scheme principal member needs to ensure they have cover to the fullest extent whenever they or their dependants are hospitalised. GAP cover can help these members to achieve this.
Check with your scheme or your healthcare intermediary the extent of the cover provided by your option as it may cause you a substantial rand shortfall against the amounts for in-hospital services, treatment and procedures charged by surgeons, anaesthetists, specialists, assistant general practitioners, physiotherapists etc. as well as charges for chemotherapy, radiotherapy and kidney dialysis. In the event of your medical scheme option not measuring up to your needs, a Gap Cover policy becomes a very useful add-on facility. There are a number of these policies available – they are short-term products which means they are
- Registered by underwriters, under the short term insurance act and not under the medical schemes act as is the case with medical schemes
- Cancellable at the instance of the particular short term underwriter
- Subject to rules which are not governed by the rules to which medical aid schemes must subscribe, which puts them outside the scope of influence of the Council for Medical Schemes (CMS) and it’s Regulator, the Registrar of Medical Schemes.
The CMS believes that GAP Cover policies do the work of medical schemes (the demarcation issue) and should thus be disallowed in their present form. This issue became the subject of litigation which was lost by the CMS and thus GAP cover, which was “on hold” during the dispute, is once again being promoted by insurers.
Medical scheme members should refer to the companies who act as their intermediaries such as IHS to clarify the various issues below so as to receive best advice in deciding on the appropriateness or otherwise of a GAP cover policy for their situation. viz
- General waiting period under the policy
- Availability of cover under pregnancy ie whether there is a maternity or confinement waiting period
- Which dependants are permitted for cover under the plan
- Which expense categories are not included for benefit ie specific exclusions
- What is the level of cover provided by the member’s medical scheme option, usually measured in units of 100% of NHRPL (National Health Reference Price List) and also, what is the comparative cover (ie per cent of NHRPL) provided by the GAP cover policy – remember, this will exclude the actual hospital accommodation which in all likelihood will be pretty well fully covered by the medical scheme itself
- simplicity in submitting claims
You, as a medical scheme member should approach your healthcare broker for full advice, and particularly, you should not make decisions on this important aspect without contacting IHS, who have the necessary accreditation and experience.
Remember, it is not unusual for GAP cover policies to have their benefit levels changed during the year – your intermediary will need to keep abreast of these changes on a “regular review” basis.
