There is often a shortfall between what a medical scheme pays and the actual cost of an in-hospital procedure or treatment. This arises because service providers are entitled to charge more than the medical scheme rate.

Some Hospital and Comprehensive Medical Plans offer cover at 100%, 150% or 200% of medical scheme rates for hospitalisation only, while the actual costs could be up to 500% of medical scheme rates.

The shortfall would then become your out of pocket expense. You can avoid this nasty surprise if you have GapCover® because you will have additional cover under these circumstances.

In other words, GapCover® will cover the difference between what your medical scheme will pay and the actual cost of your in-hospital doctor’s bills up to a maximum of 500% of medical scheme rates*.

Here are some examples of common medical procedures, with the combined charges of the specialist and anaesthetist opposite each. The third column illustrates the payment shortfall an individual on a standard, 100% of MSR (medical scheme rate), scheme option would experience.

These are just a few examples of the many different treatments and operations covered by GapCover®.

* The maximum amount that will be paid towards in-hospital expense shortfalls is calculated at five times (or 500% of) the medical scheme tariff defined by your medical scheme; less the amount payable or actually paid by your medical scheme or one times the medical scheme tariff, whichever is the higher, limited to R198 660 per beneficiary per annum.

The maximum amount that will be paid towards in-hospital expense shortfalls is calculated at five times (or 500% of) the medical scheme tariff defined by your medical scheme; less the amount payable or actually paid by your medical scheme or one times the medical scheme tariff, whichever is the higher, limited to R211 573 per beneficiary per annum.

Yes, GapCover® and Combined Cover policies can be used in conjunction with any registered South African medical scheme.

No, you will need to move to the Combined Cover option that includes cover for co-payments. (Refer to the GapCover application form.)

Combined Cover provides cover for the difference in the amount charged by a Registered Medical Professional and the Medical Scheme Rate for services rendered while admitted in hospital, as well as procedural co-payments and hospital admission fees (the excesses imposed in terms of your medical scheme rules) for procedures performed as an in-patient or an out-patient, including Specialized Radiology such as MRI and CT Scans subject to the overall annual limit and limited to R18 640 per event. This benefit also includes additional cover up to R18 105 for the co-payment charged when using a non-DSP Hospital, limited to one event per calendar year, per policy.

What makes it so great is that there is no limit on the number of Co-Payments you can claim for. You could for instance claim for ten scopes a year to a limit of R18 640 per event per beneficiary and subject to your OAL of R211 573.

Here’s an example to clear up any confusion:

Mary is admitted to hospital for stomach ache and in order to diagnose her properly, she undergoes a colonoscopy (with a co-payment of R4 000), followed by a specialised scan (with an additional co-payment of R4 000) and finally a laparoscopy (with a co-payment of R4 000). All in all, Mary’s stomach ache (the event) would have cost her R12 000 in co-payments. This falls within the R17 000 Co-Pay cover limit per event. Assuming Mary has not already reached her OAL, she will be able to claim this full amount from her CoPay benefit.

GapCover® is a product underwritten by Western National Insurance Company Limited and administered by Gaprisk Administrators. GapCover® has been a trusted provider of Gap Cover for South Africans since August 2010.

The Council of Medical Schemes has specific codes for procedures and each code has a specific rate, which is used as a guideline by medical schemes.

GapCover® and Combined Cover options do not include benefits for PMB claims. However, Elite Cover option include benefits for planned PMB admissions and is subject to a maximum of 15 070 per policy, per year.

No, normal visits to your GP or specialist, and auxiliary services on a day-to-day basis are not

part of your GapCover® policy benefit unless otherwise specified in the policy wording.

GapCover® and Combined Cover options however do cover you for the shortfalls on Gastroscopies and Colonoscopies in a GP or Specialists rooms, limited to two scopes per beneficiary per annum.

GapCover® and Combined Cover options do not include benefits for PMB claims. However, Elite Cover option include benefits for planned PMB admissions and is subject to a maximum of R15 070 per policy, per year.

Prescribed Minimum Benefits (PMB) are a set of defined benefits to ensure all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable. PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of:

• any emergency medical condition;
• a limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs);
• and 27 chronic conditions (defined in the Chronic Diseases List).

Yes, a premium increase may be applied on an annual basis.

No, intermediary and administration costs are included in your monthly premium.

The first premium will be debited within the first month of cover.

No, GapCover® is a separate insurance product administrated by a different company, therefore it will be a separate monthly deduction.

A debit order will be deducted on the next working day.

GapCover® and Combined Cover is available to individuals who are members of a registered South African medical scheme.

GapCover® does not have an age restriction.

Yes, GapCover® does not have an age restriction.

No medical examination required.

Cover is provided for you, your spouse or life partner and all children registered as child dependents on your medical scheme as well as your GapCover® policy. Dependents who are not registered on your policy, will not enjoy cover.

Pregnancy is not covered by the policy as regular consultations and pathology is not an in-hospital service.

Confinement (Childbirth):  As a rule, GapCover does not pay for PMB’s (Prescribed Minimum Benefits).

Remember however, if you sign up for gap cover when already pregnant you won’t be covered for elective caesarean section. Unfortunately, providing gap cover with no underwriting on pregnancy is not possible. As with most insurers and medical schemes, we need to manage the risk on behalf of our other policy holders. Underwriting is therefore applied on all pre-existing conditions, including pregnancy.

New-born babies are covered from birth with no waiting periods, provided the baby is registered on the policy within 90 days from date of birth. Should the baby be registered more than 90 days after birth, waiting periods will apply.

Yes, your new spouse or life partner can be covered on the policy. Normal underwriting will apply. Please note that dependent registrations are required and will not be backdated. GapCover® allows for only one spouse or life partner to be registered as a dependent.

No, GapCover® allows for only 1 (one) spouse or life partner to be registered as a dependent.

Your policy documents will be emailed to you within 1 (one) week of registration of your application, provided that the Application form was completed in full and no additional information is required. Documents can be posted on request.

Cover will commence on the 1st day of the month for which your first premium is received. Terms and conditions apply. For example, there are Waiting Periods to consider:

1. During the first 3 (three) months of membership, a General Waiting Period applies, unless the Insured Event that required hospitalisation was caused by an accident that occurred after the commencement date of cover.
2. During the first 12 (twelve) months of membership, a Pre-existing condition Waiting Period will apply.
3. Waiting periods differ based on your specific circumstances. Consult a GapCover® specialist for further clarity.

It is advisable to submit the GapCover® claim as soon as your medical scheme has paid their portion of the account, but not later than 4 months of receipt of the medical scheme payment.

A completed claim form, available on request and must be accompanied by detailed copies of all relevant doctors’ accounts, a clear copy of the Hospital account, detailed Medical Scheme claims statement reflecting processing and payment of the applicable accounts, a copy of your medical scheme authorisation confirmation and a copy of the medical scheme membership certificate.

All claim payments are made directly to the debit order account details. For security purposes, should the bank details for payment of claims differ from the debit order account details, proof of bank details must be provided with your claim in the form of a bank statement.

Yes, any changes must be communicated to GapCover® via email (admin@gaprisk.co.za) within 30 days of the change. (Please attach a copy of your updated medical scheme membership certificate as confirmation of changes in respect of your dependents). Kindly contact the Administrator for assistance with any other changes. In the event that your child reaches the age of 26 years, the child will no longer be covered under this policy (unless the child is registered as a special dependent).

No. Although the GapCover® policy runs in conjunction with a medical scheme, the GapCover® waiting periods will not be affected when changing medical schemes.

The policy will be terminated when the principal member cancels the policy in writing or when the principal member allows the policy to lapse.

To cancel the policy, the Administrator must be given 1 (one) calendar months’ notice to cancel the policy. (A cancellation form is available on request.)

It will be cancelled automatically once 3 (three) consecutive premiums have not been received, as the policy will then be three months in arrears.

Yes, within 3 months from date of cancellation. If the policy is cancelled for a period longer than 3 months, a new application form must be completed.

No. Combined Cover provides cover for specified co-payments on procedures and scans performed in- and out-of hospital. Co-payments on medication and doctors’ consultations are not covered.

A typical example of an incident or event will be:

You are a medical scheme member who suffer from persistent migraines, your medical practitioner requests an MRI (co-payment of R2 740 applies), the MRI indicates bleeding on the brain and you are admitted into hospital for treatment (hospital admission fee of R1 640 applies), while receiving treatment, a second MRI is done (co-payment of R2 740 applies) which confirms that you need an operation. The co-payments for both MRI scans and the admission fee will be seen as one event.

A 3-month general waiting period shall apply in respect of all claims received in this period unless the claim is as a result of an accident.

A 12-month pre-existing condition waiting period shall apply in respect of all pre-existing conditions.

Any previous cover with similar benefits may be taken into consideration when calculating your waiting periods.

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