Eyecare Insurance: Filling The Gap

Gap cover is a type of insurance that covers the shortfall between what your medical scheme pays and what a private doctor or hospital charges. This type of insurance is designed to pay the 'gap' or shortfall between what your medical scheme tariff pays and what you are billed by a private doctor or specialist in-hospital. For example, if your medical scheme tariff for an in-hospital procedure is R600 but you are billed R1100, gap cover should cover the difference of R500. However, it's important to note that gap cover insurers do not cover all procedures and medical conditions, so reading the fine print is essential.

Gap cover is designed to pay the 'gap' or shortfall between what your medical scheme pays and what a private doctor charges

Gap cover is a separate insurance product that covers the 'gap' or shortfall between what your medical scheme pays and what a private doctor charges. This means that if your medical scheme tariff for a specialist visit is R600 (in-hospital) but the bill is R1,100, the gap cover should pay the difference of R500.

However, it is important to note that gap cover insurers are not bound by the regulations of the Medical Schemes Act of 1998, but by the Short-term and Long-term Insurance Acts. As such, it is important to read the fine print of your gap cover policy as it may not cover everything you expect it to. For example, gap cover usually does not include services rendered by allied health professionals such as dietitians, audiologists, chiropractors, speech therapists, and occupational therapists. Additionally, gap cover generally does not cover consultations before or after in-hospital treatment, medicine, or disposable items in and out of the hospital.

In recent years, the responsibility for paying the largest share of medical practitioners' costs has shifted from medical schemes to gap cover providers, leading to a severe increase in the cost of medical practitioner shortfall claims each year. As a result, many gap cover providers have introduced a new way of calculating how much of the co-payment they will cover. Some will pay up to twice what your medical scheme has paid, while others will pay up to five times in a match-pay system, depending on the type of policy you have.

It is also worth noting that gap cover is only available to those who are already members of a medical scheme and that only one policy is required to cover a single member and any dependants.

Gap cover usually requires only one policy for a single member and their dependants

Gap cover is a form of insurance that pays the 'gap' or shortfall between what your medical scheme covers and what a private doctor charges. It is generally inexpensive and can be taken out if you or your family are already members of a medical scheme. However, it is important to read the fine print as there may be unexpected exclusions.

It is important to note that gap cover is not governed by the Medical Schemes Act of 1998 but by the Short-term and Long-term Insurance Acts. This means that it is an insurance product and is run for profit.

Gap cover payments are calculated based on the difference between what your medical scheme pays and the bill from a private doctor or specialist. In the past, gap cover used to pay the full difference, but this is no longer sustainable due to spiralling healthcare costs. Now, many gap cover providers have introduced a payout system based on what your medical scheme pays, which may be up to twice or five times the amount, depending on the policy.

While gap cover can provide peace of mind, it is important to understand what it does and does not cover.

Gap cover is an insurance product and does not fall under the regulations of the Medical Schemes Act of 1998

Gap cover insurance is a supplemental form of health insurance that helps cover various out-of-pocket expenses, such as deductibles, copays, and coinsurance. It is often paired with a high-deductible health plan (HDHP) to protect consumers from high out-of-pocket costs. Gap health insurance is not subject to the same rules and regulations as major medical insurance and is instead regulated by short-term or long-term insurance acts. It is important to note that gap cover is not a substitute for a medical scheme or medical insurance plan.

While gap cover can help reduce out-of-pocket expenses, it does not guarantee that consumers will never experience a shortfall. Additionally, gap cover policies have limits on the maximum payout per client per year. It is also important to carefully read the fine print of any gap cover policy, as they often have exclusions and limitations on what they will cover. For example, gap cover typically does not pay for medication, home nursing, routine medical examinations, or out-of-hospital dental treatments.

In South Africa, gap cover is regulated by the Short-term and Long-term Insurance Acts, specifically not falling under the regulations of the Medical Schemes Act of 1998. This means that gap cover insurers are run for profit and are allowed to apply underwriting rules. As a result, gap cover insurers have had to manage their expenditures carefully to remain financially viable in the face of rising healthcare costs.

Overall, while gap cover can help reduce out-of-pocket expenses, it is important to understand its limitations and exclusions. Consumers should carefully review their scheme benefits and the gap product's fine print before purchasing gap cover insurance.

Gap cover is not designed to pay for ward costs in a hospital or step-down facility

Gap cover is a form of insurance that pays the 'gap' or shortfall between what your medical scheme covers and what a private doctor charges. However, it is important to note that gap cover is not designed to pay for ward costs in a hospital or step-down facility.

Ward costs refer to the expenses associated with a patient's accommodation in a hospital. Typically, hospitals offer different types of wards or rooms, such as private, semi-private, or standard ward options. The cost of these rooms can vary, with private rooms being the most expensive and standard wards being the most affordable. While gap cover can help with the costs of private doctors and specialists in-hospital, it does not cover the expenses related to the patient's stay in the hospital, including the room or ward charges.

In some countries, public funding or health insurance programs may cover standard ward accommodation in hospitals. For example, in Canada, the provincial and federal health insurance program, OHIP, covers standard ward accommodation (four beds to a room) through the country's Medicare program. However, if patients prefer a private or semi-private room, they or their insurance company will be charged a premium rate.

It is important for individuals to carefully review the terms and conditions of their gap cover insurance to understand what is and is not covered. While gap cover can provide financial protection in certain medical situations, it does not cover all possible expenses related to hospitalisation. Therefore, individuals should be aware of the limitations of their gap cover insurance and plan their finances accordingly in case of any medical emergencies.

Additionally, it is worth noting that gap insurance is also a term used in the context of auto insurance. In this context, gap insurance covers the difference between what a vehicle is currently worth and the amount owed on it if it is badly damaged or totalled in an accident. This type of gap insurance is unrelated to medical or healthcare costs and instead focuses on providing financial protection for vehicle owners.

Gap cover generally doesn't cover cosmetic surgery, obesity treatment, laser eye surgery, dental implants, or fertility treatment

Gap insurance is an optional auto insurance coverage that applies if your car is stolen or deemed a total loss. It covers the difference between what you owe on a car lease or loan and the amount paid out in a total loss settlement from an auto insurer. In other words, it covers the "gap" between what a vehicle is currently worth (which your standard insurance will pay) and the amount you actually owe on it.

Gap cover, on the other hand, is a type of insurance that is added on top of a basic hospital plan. It is designed to pay the 'gap' or shortfall between what your medical scheme pays and what a private doctor charges.

While gap insurance is specific to auto insurance, gap cover is related to medical insurance. It is important to note that these are two distinct types of insurance with different coverage options and exclusions.

Gap cover generally does not cover cosmetic surgery, obesity treatment, laser eye surgery, dental implants, or fertility treatment. These types of procedures are typically considered elective or non-essential and are, therefore, excluded from coverage.

Cosmetic surgery, such as plastic surgery or Botox injections, is often not covered by gap cover as it is usually seen as an optional procedure rather than a medical necessity. Obesity treatment, including weight loss surgery or weight management programs, is also typically excluded from gap cover as it falls under weight or BMI-related procedures, which are often not covered.

Laser eye surgery, or refractive surgery, is another type of elective procedure that is usually not covered by gap cover. This type of surgery corrects vision problems such as nearsightedness, farsightedness, and astigmatism, but it is not considered medically necessary and, therefore, is often excluded from coverage.

Dental implants, which are artificial tooth roots that are surgically anchored to the jaw bone, are also generally not covered by gap cover. Dental treatments, especially those that are elective or cosmetic in nature, are often excluded from coverage under gap insurance policies.

Lastly, fertility treatment, including procedures such as in vitro fertilization (IVF) or intrauterine insemination (IUI), is typically not covered by gap cover. Fertility treatments can be costly, and gap cover usually does not provide reimbursement for these expenses.

It is important to carefully review the terms and conditions of your specific gap cover policy to understand exactly what is and is not covered. Exclusions and limitations may vary depending on the insurance provider and the specific plan chosen.

Frequently asked questions