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03 March 2023
Gap cover in South Africa is a type of insurance product that provides additional financial protection for medical expenses that are not fully covered by your primary medical aid.
Even with a medical aid, you may still be responsible for certain out-of-pocket expenses such as hospital co-payments, deductibles and fees for medical specialists that exceed your medical aid’s rates furthermore, Gap Cover is designed to help cover these additional expenses, so you don’t have to pay for them out of your own pocket.
A report published by the Council for Medical Schemes (CMS) in 2021 states that the total out-of-pocket payments by medical aid members increased from R29.8 billion in 2016 to R36.7 billion in 2021 at a consolidated scheme level including both open and restricted medical schemes. Moreover, this equates to 23% more out-of-pocket expenses paid by members from 2016 to 2021.
Having gap cover does not mean that all out-of-pocket expenses will automatically be covered, as this is a misconception throughout the industry which leads to frustration and confusion from gap cover policyholders.
Gap cover polices are not designed to cover day-to-day shortfalls namely, medicine, GP visits, and charges once your medical savings account has been depleted.
It is designed to cover in-hospital treatment and procedures and certain defined out-of-hospital procedures.
The table below contains some common procedures that frequently result in medical expense shortfalls additionally, the Rand amounts that were not covered by the medical aid and required payment by the member. These are actual Zestlife Gap Cover claim amounts paid during 2021/2022:
Examples of medical procedures that are frequently not covered in full by medical aids | Examples of medical expense shortfalls paid by Zestlife Gap Cover in 2021/2022. |
---|---|
Natural Childbirth | R40 189 |
Caesarean Section Childbirth | R34 127 |
Tonsillectomy | R62 445 |
Hernia Repair | R57 263 |
Breast Cancer Surgery | R48 142 |
Knee Replacement Surgery | R42 937 |
Hip Replacement Surgery | R58 143 |
Ankle Surgery | R43 920 |
Shoulder Surgery | R61 182 |
Hand Surgery | R39 381 |
Foot Surgery | R45 354 |
Lung Surgery | R49 199 |
Brain Surgery | R77 583 |
Liver Surgery | R38 825 |
Kidney Surgery | R39 206 |
Intestine Surgery | R33 431 |
Heart Surgery | R115 000 |
Heart Valve Replacement Surgery | R124 721 |
Surgery for Fractured Arm | R59 006 |
Eye Surgery | R49 175 |
Ear Surgery | R33 327 |
Cancer Treatment | R146 694 |
Spinal Surgery | R62 901 |
It is highly recommended that you choose the right gap cover option to suit you and your family’s needs and budget.
Contact us today and we will gladly assist you.
Click here for more product information or to apply online.
The information contained in this communication, including attachments, is not to be construed as advice in terms of the Financial Advisory and Intermediary Services Act of 2002 (“FAIS”) as the writer is neither an appointed representative of Zestlife, nor a licensed financial services provider as contemplated in FAIS. Please consult your Financial Adviser or Zestlife should you require advice of a financial nature and/or intermediary services.
Author - Elize Krüger
Elize Krüger, Marketing Manager and Content Creator
Elize is a seasoned public relations and content writer with over 10 years of experience in the financial services industry. She plays a crucial role in developing and promoting informative content by effectively using the rich expertise and knowledge of key individuals within Zestlife. Elize is closely involved with product development and keeps up to date with insurance industry trends and business development. She is passionate about creating educational content and is dedicated to providing valuable insights to Zestlife’s growing audience.