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Medical Aid Gap Cover (Medical
Shortfall Cover)
What is GapCover?
GapCover provides a benefit equal to actual cost limited to 4 times
the NHRPL (National Health Reference Price List) less payment for
treatment received for services rendered by doctors and/or
specialists while hospitalized as an inpatient.
GapCover is a product underwritten by Western National Insurance
Company Limited.
Who can apply for GapCover?
GapCover is available to individuals currently on a medical scheme
and 65 years of age or younger.
What does GapCover cost?
Option 1: R95 per month (max benefit / year R1 000 000 - 4 x NHRPL)
Option 2: R80 per month (max benefit / year R150 000 - 4 x NHRPL)
(For individuals who qualify, irrespective of family size.)
Why GapCover?
In most cases, members have a shortfall between what the medical
scheme pays and the actual cost, because the Service Providers are
entitled to charge more than the National Health Reference Price
List (NHRPL) rates. The shortfall then becomes the member's
responsibility and he/she will therefore need to have additional
cover in these circumstances.
Some Hospital and Comprehensive Medical Plans offer cover at 100%,
150% or 200% of NHRPL rates for hospitalization only, while the
actual costs could be more than 400% of NHRPL. GapCover will cover
the difference between what your medical scheme will pay and the
actual cost of in-hospital doctor's bills up to a maximum of 400% of
NHRPL.
Waiting Period
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Incurred for a period of 3 months from inception date except in
the event of emergencies.
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Maternity benefits will only accrue after a 12-month waiting
period.
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12-month general waiting period on pre-existing conditions.
Please Note
Confirm benefits covered, exclusions and the rules of the specific
medical scheme, as GapCover cannot cover shortfalls within overall
annual hospital limits or co-payment on certain procedures, as
stated by the medical scheme rules.
Should your scheme have an annual hospitalisation limit, GapCover
will not be liable to pay the difference between what your scheme
covers and the cost of the account.
Example:
If the medical scheme specifies that it will cover R10 000 for a
prostheses, the member undergoes a knee operation and the prostheses
costs R25000, GapCover will not be liable to pay the difference.
Get a quote for Gap Cover:
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