Sometimes a person has an insurance policy, but when he has a medical emergency there is a difference between what the doctors charge, and what Medicaid is willing to pay. That difference is called a Gap. Gap cover, therefore, is a short-term insurance policy that provides for the difference between what the doctors and specialists charge, and the medical aid rates.
In South Africa, Gap Cover works with your Medicaid providers, to give you a more balanced and effective cover when needed. Therefore, rather than facing the shock and financial burden of unforeseen hospital expenses, specialists fees, and so on, including scans, counseling, and such bills, it is a better option to have a gap cover to take care of such spending.
The best gap cover in South Africa would be those that have over the years built a good and solid reputation for making prompt settlements to assist their policyholders.
Top Gap Cover in South Africa
ZestLife offers three gap cover products with contributions that vary from R372 to R568 per family per month. Gap cover is provided at up to 500% of the medical scheme rate, and the company does not have an annual maximum claims limit. In-hospital cover extends to over 50 procedures conducted out of hospital; however, the maximum entry age is 64 years.
Zestlife mandates a 10-month waiting period on birth-related claims, while the first 6 to 12 months would see you not get full cover for certain claims.
However, the benefits are clear: Zestlife covers any Shortfalls on doctor’s charges, R50 000 for accidental death cover and accidental injury cover, Co-payment cover for hospital treatments, and Once off payments to policyholders who have cancer.
Stratum Benefits is a well-known provider of Gap Cover. This company offers four gap cover products, and their premiums vary from R248 to R679 per family per month. The company pays benefits at 500% of the scheme rate on all the options.
Exclusions are standard: the company mandates a three-month general waiting period for a new member, and those with a pre-existing condition must undergo a waiting period of six months. For those who must undergo certain procedures, a 10-month waiting period applies. However, the good news is that there is no maximum age limit and no claims limit.
Some of the benefits of this company are in-hospital gap cover, trauma counselling, cancer diagnosis, and road accident cover on all the options. However, one can get accidental death benefits on the higher-end packages.
Turnberry gap cover charges monthly premiums ranging from R150.00 – R310.00 on its packages. The company provides as much as 500% cover for in-hospital stays. The company’s Elect-A-Care-Plus package helps you cover in-hospital co-payments, out-of-hospital benefits, and various deductibles such as dentistry, scans and scopes, in-hospital payments, and even out-of-hospital scans.
Liberty Essential Gap Cover
Liberty Essential Gap Cover is a trusted medical scheme that provides added cover for treatment cost shortfalls at an affordable rate. The policy provides up to R173 000 in benefits for persons covered by the policy.
This scheme offers in-hospital cover for doctor and specialist charges. One can get 3 times the medical scheme tariff. This scheme offers out-of-hospital cover for doctor and specialist fees, times 3 of the tariffs. The scheme offers Emergency Room Cover for accidental injury.
Ambledown is a company that is well known in the South African gap cover industry. In fact, this company has 13 products that offer different levels of cover, charging between R150 to R350 per family per month, and offering benefits ranging from 300% or 500% of the scheme rate, depending on the product.
Ambledown gap cover products are offered through Constantia and Hollard Insurance, and while they even have ‘Senior’ options for individuals aged 71 years and above, some of the products have age limits.
The company mandates a 12-month waiting period on scopes and certain surgeries. Preexisting conditions are excluded.
Complimed Gap Cover
Complimed gap cover is a health insurance policy that is specially designed to complement PSEMAS (Government Medical Aid Fund). When it became clear that the government medical aid could not take care of all the needs of the policyholders, a separate fund was set aside to cover the difference between what your medical aid fund covers and the fees being demanded by doctors and specialists.
Of course, you have to be a member of PSEMAS to qualify for Complimed cover.
In-hospital specialist treatment, Accommodation, and fixed tariff hospital procedures.
Maternity Benefits, including treatment, and any neonatal ward fees or ICU fees.
Medicine, materials, and consumables are also covered.
Xelus’ Fusion package is a Gap Cover provider that focuses on employer groups. It provides cover for all types of shortfalls, and it does not matter which medical aid the client uses. Xelus gap cover fills the gap between what medical aid pays and what specialists charge during a hospital stay.
Xelus provides comprehensive gap cover that includes cover for cancer treatment technologies, in-hospital stays, and also gap cover for any deductibles arising from your stay at the hospital. Usually, this company works directly with employees.
Xelus excludes claims from self-inflicted injuries, cosmetic surgery, and also attempts to take one’s own life. There is a three-month waiting period for new policyholders, and 12 months for maternity. Certain pre-existing conditions demand an extra waiting period
Sirago is a company that provides gap cover with four products. Premiums range from R218 to R645 per family per month and the cover provided is effectively 300% to 500% of the scheme rate. The company provides additional cover in the form of prescribed minimum benefits (PMB) benefits on all plans. The top-tier options also provide cancer cover, co-payments, admission, and penalty fee cover.
Although there is a maximum entry age (40 years, or 65 years) for the Basic Gap Cover and Gap Cover products, respectively. The top tier products have no age limits.
The company mandates a general waiting period of three months for new members, and members with pre-existing conditions have to wait for the first 12 months.
Jenius provides Gap Cover to the tune of up to 500% of the medical aid tariff, this company provides products that are open to individuals under 60 years of age or groups below 65 years.
The company mandates a general three-month waiting period and, a 12-month maternity waiting period.
There is also a 12-month waiting period for pre-existing conditions and a complete exclusion for pre-diagnosed cancers.
This company provides cover for your immediate family; wife and children, however, there are a few limits.
The company sets its cancer co-payments cover to 20%.
Hospital consumables are limited to a set amount (contact the company to find out)
The company only covers Cancer or oncology-related surgery up to 600% with Jenius gap cover.
Santam is a solid name in all things insurance. This company provides gap cover for your medical treatments starting from R125 per month. The company mandates a general waiting period of 3 months on all benefits, 12 months for maternity benefits, and also a 12 months waiting period for pre-existing conditions.
The company does not cover the cost of treatment for obesity, or treatment for cosmetic surgery unless the need comes from trauma or as a result of oncology treatment. The company also does not cover any penalty or co-payment agreement that is outside a medical scheme, or that does not comply with the benefit rules.
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Depending on your particular needs there are several options for you to choose from. However, one must keep in mind that these companies generally shy away from pre-existing conditions, and those that do generally observe a waiting period sometimes up to a year. Furthermore, you will find that there is a waiting period of 3 months for all new clients.
Please ensure that you read the fine print before going ahead to pay for any policy, so as to ensure that you are paying for a policy that will meet your needs.