Gap cover is a short-term insurance policy that bridges the difference between what your medical aid pays and what doctors and specialists actually charge. Because many specialists charge several times the medical scheme rate, members can be left with a large shortfall to pay from their own pocket, even for in-hospital treatment. Gap cover absorbs that difference, along with certain co-payments and sub-limits, so an operation or hospital stay does not leave you with an unexpected bill. It works alongside your medical aid, not instead of it, and is not a medical scheme in its own right.
Even with a good medical aid, an unexpected shortfall can catch you off guard. Specialists and surgeons often charge more than your scheme covers, and the difference lands on you. Gap cover is designed to close that gap. Below, Bloom explains what gap cover is, why shortfalls happen, exactly what gap cover pays for, and how to apply. If you would like to protect yourself from these costs, you can compare our gap cover options.
Key takeaways
| • Gap cover pays the difference between your medical aid rate and what specialists actually charge, so you are not left out of pocket. |
| • It works alongside your medical aid, so you need an active medical scheme membership to take it out. |
| • It covers more than tariff shortfalls, including co-payments, certain sub-limits, casualty, oncology and maternity benefits. |
| • Waiting periods and exclusions apply, so it is best to take out gap cover before you need it. |
What is gap cover?
Gap cover is a supplementary short-term insurance policy that covers the difference, or “gap,” between the fees healthcare providers charge and the amount your medical aid pays. It typically applies to in-hospital treatment and certain defined out-patient procedures, where specialists such as surgeons, anaesthetists and physicians often bill well above the medical scheme rate.
It is important to know that gap cover is not a medical aid and is not a substitute for medical scheme membership. It is an add-on that works alongside your medical aid to give you an extra layer of financial protection.
What is a medical shortfall, and why does it happen?
A shortfall is the portion of a medical bill you have to pay yourself because it exceeds what your medical aid covers. Shortfalls are more common than many people realise, and they usually happen for one of these reasons:
| • Specialists charging above the scheme rate. Many specialists bill at several times the medical aid tariff. Your scheme pays its rate, and you are left with the difference. |
| • Co-payments and deductibles. Some schemes require you to pay a set amount or a percentage towards certain procedures and scans. |
| • Sub-limits. Schemes may cap what they pay for specific items, such as internal prosthetic devices or certain scans, leaving a shortfall on costly procedures. |
| • Out-of-network providers. Using a provider outside your scheme’s network can reduce your cover and increase what you pay yourself. |
What does gap cover pay for?
Gap cover does more than top up specialist bills. Depending on the plan you choose, Bloom Gap Cover includes a range of benefits, subject to the policy terms, waiting periods and limits:
| • Tariff shortfalls. Cover for the difference between what specialists charge for in-hospital treatment or surgery and what your scheme pays. |
| • Co-payment cover. Help with co-payments and deductibles applied to defined procedures, including certain out-patient procedures that would attract a co-payment in hospital. |
| • Sub-limit (limit extender) cover. Additional cover where your scheme places a rand limit on internal prosthetic devices such as joint replacements, spinal fusions and pacemakers, and on sub-limits for MRI, CT and PET scans, endoscopes and lens implants. |
| • Casualty cover. Cover for emergency treatment at a casualty facility following an accident, plus a rehabilitation benefit for sports injuries. |
| • Oncology cover. Protection against oncology co-payments and tariff shortfalls, and a once-off lump sum on a first cancer diagnosis to help with related costs. |
| • Maternity cover. Cover for tariff shortfalls on gynaecologist or GP consultations during the second and third trimester, and gynaecologist or paediatrician consultations after birth, with a benefit for premature birth. |
| • Accident and waiver cover. A lump sum on accidental death or permanent disability, which increases if the event resulted from a proven crime, plus cover of your medical scheme contributions and gap premiums for a period if the main member or spouse dies or is permanently disabled in an accident. |
| • Added extras. Access to a medical second opinion from leading specialists, and cover for medical emergencies while travelling abroad. |
Benefit amounts and limits differ between plans, and an overall annual limit per person applies. You can see how the plans compare on the compare gap options page.
Do I need gap cover?
Gap cover is worth considering for anyone on a medical aid who could be exposed to specialist shortfalls, which is most members. It is especially valuable if you or your family are likely to need surgery, specialist care, cancer treatment or maternity care, or if your scheme applies co-payments and sub-limits. For a relatively small monthly premium, it protects you from bills that can run into tens of thousands of rand. Because it complements your medical aid, it is a practical way to strengthen your cover without upgrading to a more expensive scheme option.
How to apply for gap cover
Applying with Bloom is straightforward:
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Check you have a medical aid. Gap cover complements your primary cover, so an active medical scheme membership is a requirement. |
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Prepare your documents. Have your ID, proof of your current medical aid membership and your banking details ready. |
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Compare and choose a plan. Look at Bloom’s gap cover options and pick the one that fits your needs and budget. |
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Apply and review the terms. Submit your application, and make sure you understand the waiting periods and exclusions before your cover starts. Bloom can guide you through this. |
Waiting periods and exclusions
As with medical aid, waiting periods and exclusions apply to gap cover. They exist to keep the cover fair and sustainable for everyone. The main ones to know are:
| • A general waiting period. A three-month period from your start date during which no claims can be submitted, typically applied to individual (non-group) members. |
| • A waiting period on certain procedures. A three-month waiting period may apply to specific listed procedures. |
| • A pre-existing condition waiting period. A longer waiting period applies to claims relating to any condition you or a dependant had, or received advice or treatment for, before your cover started. |
Waiting periods and exclusions can vary by plan and provider, so always confirm the exact terms that apply to the option you choose. This is also why it makes sense to take out gap cover before you need it, rather than waiting until a procedure is on the horizon.
Bloom’s gap cover options
Bloom offers affordable gap cover through two plans, so you can choose the level of protection that suits you:
| • Gap Core. Solid, affordable cover for the essentials, including tariff shortfalls, co-payments and key added benefits. |
| • Gap Max. Our most comprehensive option, with higher benefit amounts and enhanced cover across the board. |
Not sure which is right for you? Compare Bloom gap options side by side, or speak to our team for guidance based on your needs and budget.
Close the gap in your coverDon’t let a specialist shortfall catch you off guard. Bloom Gap Cover works alongside your medical aid to protect you from unexpected bills. Fill in your details and we will call you back. |
Frequently asked questions
Protect yourself from unexpected medical bills
A medical aid is essential, but it does not always cover the full cost of specialist care. Gap cover closes that gap, giving you peace of mind that an unexpected shortfall will not become a financial setback. Taking it out before you need it means you are protected when it matters most.
Explore Bloom’s gap cover options, compare gap options side by side, or take a look at our medical aid plans if you need foundational cover first. To get started, get in touch and we will call you back.
