No financial planning discussion would be complete without a discussion about top-up cover, or gap cover. Gap cover essentially covers costs that are not covered by your medical scheme yet are incurred by you when you visit a hospital.
Most medical schemes cover 100% or 150% of the medical aid rate for in-hospital costs. This rate will cover most hospital costs such as the hospital stay, pathology, radiology and even medicines. But most specialists, even those who have their rooms in the hospital, charge above medical aid rates. They can charge as much as 300% or 400% of the medical aid rate.
Gap cover is a short-term insurance product designed to assist you with covering the shortfalls that may arise during a hospital admission; this may be for a medical procedure where the doctors and specialists charge a higher rate than what your medical scheme pays, or it may be when you are required to pay a co-payment or upfront cost for a procedure. Although gap cover does not cover out-of-hospital procedures, it does cover certain listed procedures performed on an out-patient basis.
I refer my clients to African Unity Health, and on their brochure they have cited some examples of claims they paid last year.
| PROCEDURE | SPECIALISTS CHARGED | MEDICAL SCHEME PAID | SHORTFALL/GAP PAID |
| Caesarean section | R 18 900 | R 5 024 | R 13 876 |
| Tonsillectomy | R 5 183 | R 1 728 | R 4 005 |
| Knee replacement | R 22 371 | R 15 394 | R 6 977 |
| Natural childbirth | R 12 000 | R 5 859 | R 6 141 |
| Coronary bypass | R 103 328 | R 48 570 | R 54 758 |
| Fractured Thumb repair | R 9 763 | R 3 276 | R 6 488 |
| The average tariff shortfall / gap cover claim in 2015 was R4 821 per event. | |||
The monthly cost is R280 per month per family, a minimal cost considering the benefits. Please contact me should you require further information regarding gap cover.