Most South African medical aid members have faced a further bill after their scheme settles their doctor or other health care professional. Your scheme only pays according to certain tariffs but these days many doctors charge above these rates. As a result the patient is liable for the shortfall between what the scheme pays and what the doctor charges. Sometimes the bill that you are liable for can be exorbitant and financially cripple you. Or you may face debt collectors and run the risk of being blacklisted. Fortunately medical gap cover is an insurance policy that covers this difference without your being out of pocket.

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Affiliated with Bonitas Medical Fund

It is important to understand some terms in medical aid billing. Medical aid rates are what your scheme will pay for a certain tariff (procedure or medical product). Private rates are what your doctor charges and it is usually higher than the medical aid rate. When your doctor talks about cash rates, they mean that they do not bill your medical aid at all (contracted out of medical aid). With cash rates, you have to pay the doctor upfront and claim back from your scheme. Most of the times these cash rates are also private rates meaning that they are higher than medical aid rates.

Medical Gap Cover To The Rescue

Until a few years ago, medical aid members were burdened by the change in billing patterns by private practitioners. Many doctors were contracting out of medical aid meaning that they would not bill your medical aid. However, they still kept their cash rates in line with medical aid rates. Over the years this has changed. Not only are more doctors contracting out of medical aid but they are also charging fees above medical aid rates.

Even some of the doctors who were contracted into medical aid (billing medical aids directly) still charged higher rates and patients had to return to their doctor’s office to cover up for shortfalls in payment. Some schemes offered higher plans that would pay out as much as 300% of medical aid rates but only for hospital bills. Medical gap cover eventually came onto the market. It is a separate insurance policy that is offered by short term insurers in South Africa.

Product Benefits

When you sign up for medical gap cover, you have the financial protection against the shortfall in payment from your medical scheme. It only applies to situations where the doctor is charging private rates. There may be many other reasons for short payment by medical aids. Medical gap cover will settle the difference after your scheme pays the doctor and there is a shortfall. However, it only applies to hospital bills – shortfalls in payment to hospitals or to doctors who treated you in hospital. Medical gap cover is only available to medical aid members.

Gap cover pays according a percentage of your medical aid rates. Your scheme usually pays 100% of its rate. But if your doctor charges three times the medical aid (300%) then your gap cover will pay for the other 200%. Most gap cover has a maximum percentage it will pay. Lower plans stop at around 300% while other more expensive plans will fork out as much as 500%. You have to lodge a claim with your gap cover insurer and provide proof of your doctor’s bill (with higher rates) as well as your schemes remittance advice showing payment (albeit short payment) to your doctor.

Cost of Gap Cover

Medical gap cover in South Africa is very affordable in comparison to medical aid contributions. Lower plans start from around R60 per month and covers all members on your plan (up to a certain limit). More expensive plans may cost around R200 to R300 per month. The percentage paid depends on the plan that you opt for. While the higher plans may seem a little pricey, consider the shortfall in payment could be tens of thousands of rands and your will quickly appreciate the benefit of medical gap cover.