Gap cover is a type of short-term insurance created to offer additional financial security to people who already have medical aid. It pays the difference between the actual rates charged by healthcare experts and your medical scheme’s tariff (MST).
In South Africa, medical aid schemes now pay healthcare providers 100%, 200%, or 300% of the plan rate. However, professional healthcare practitioners may bill up to five times the standard rate.
Taking out gap cover protects yourself and your family against this financial disparity, potentially avoiding significant out-of-pocket healthcare expenses.
Gap cover meaning - what you need to know
Gap cover is a form of insurance that helps cover the difference between the medical expenses charged by healthcare providers and the amount covered by your health insurance policy or medical aid scheme. It offers additional cover by paying for costs like co-payments, deductibles, and other out-of-pocket expenses.
How does gap cover work?
When you receive authorised medical treatment, your healthcare will cover a certain percentage or amount of the expenses. However, if the medical costs exceed the coverage limit, gap cover can pay for the remaining costs so that you don’t have to pay out-of-pocket. This includes payments for co-payments, deductibles, and other expenses.
Should you get gap cover?
Yes. Gap cover can make up the difference if you need to undergo an expensive medical procedure or suffer from a condition that isn’t fully covered by your medical aid.
Medical care costs exceed what medical aids are ready to pay, and many healthcare professionals, like specialists, charge higher fees. Therefore, even if you have medical aid, a hospital stay or illness could leave you with a hefty expense.
Gap cover offers insurance that pays for some of the shortfalls medical aid doesn’t. It essentially closes the gap, ensuring you can afford the medical care you and your family need.
Who is eligible for gap cover?
Anyone who’s an active member of a registered South African medical aid scheme qualifies for gap cover.
Depending on the plan you choose, the benefits extend to your spouse and dependent children up to a certain age.
Waiting periods
As with conventional medical aid schemes and health insurance, waiting periods and exclusions apply to gap cover.
Below are the specific waiting periods for Bloom Gap cover, but please note that these can change according to the provider you choose.
3-Month general waiting period
If you are an individual, not part of a group, a 3-month general waiting period will apply. During this period, you cannot claim for any benefits.
9-Month pre-existing medical condition waiting period
Within the first nine months of cover, a waiting period will apply where no claims can be submitted for any procedure or surgery relating to any pre-existing condition for which you have received advice or treatment 12 months prior to your cover start date.
12-Month birth, pregnancy or cancer-related waiting period
Within the first 12 months of cover, a waiting period will apply where no claims can be submitted for any cancer, birth or pregnancy-related medical issues.
How do you decide which plan is for you?
First, consider the medical aid plan you’re on, work out where the shortfalls could be and compare gap cover plans until you find one that meets your needs.
There are tons of medical aid and gap cover options, so chat with a knowledgeable insurance advisor before deciding.
How do you claim?
Gap cover requires you to fill in a claim form attached to a statement of account that reflects the procedures for which you are claiming. Once the claim is assessed, they will pay you directly if approved.
Always confirm that you have provided all the required documentation to ensure the claim process goes as smoothly as possible.
Bloom Gap Product Range
1. The Bloom Gap Max Range
- Bloom Gap Max Primary Member
Bloom’s Gap Max cover is the premium and comprehensive answer to unexpected medical expenses. This option covers the shortfall between what your medical aid covers and what hospitals and specialists charge, with many added benefits. The premiums start at R278 per month.
- Bloom Gap Max Adult Dependant
A spouse dependant will be charged adult premiums. Monthly premiums start at R190 per month.
- Bloom Gap Max Child Dependant
Child dependant will be charged child premiums until they turn 24 and a maximum of two children will be charged per family. Monthly premiums start at R91 per month. Terms & conditions apply*
2. Gap Bloom Core Range
- Bloom Gap Core Primary Member
Bloom’s Gap Core cover
is the affordable answer to unexpected medical expenses. It covers the gap between what your medical aid covers and what hospitals and specialists charge. The premiums start at R241 per month. Conditions apply.
- Bloom Gap Core Adult Dependant
A spouse dependant will be charged adult premiums. Monthly premiums start at R165 per month.
- Bloom Gap Core Child Dependant
Child dependant will be charged child premiums until they turn 24 and a maximum of two children will be charged per family. Monthly premiums start at R79 per month. Terms & conditions apply*
The bottom line
With gap insurance, you can feel more secure and lower your risk of accruing a high medical cost that you cannot afford. As usual, do your research, consider your options, and choose the cover that will work best for you.
