How Gap Cover works

Various insurances that we all need

WellSpent has always championed the importance of having great Gap cover in place. We wrote a prior article about the basics of Gap cover, which is the perfect place to get on top of the essentials before getting into the specifics below.

We’ve been waiting patiently for an opportunity to share a real life example of how Gap cover works with you, and that opportunity appeared when one of our editors recently had a baby girl.

In this article, we’ll talk you through the mechanics of claiming against your Gap cover as well as quantify the savings, using a real-life example.

Babies: expensive

The mom was the principal member of the medical aid plan. She had a hospital plan, which essentially means that her medical aid pays her ‘in hospital’ costs only, and up to medical scheme rates for that particular scheme.

Mom had been a member of the current Gap cover for a period of 26 months. It was important for the mom to know how long she had been a member of the Gap cover as this specific Gap cover had a specific waiting period of 10 months for childbirth claims. Some other policies have a 12 month waiting period.

She’s paying R285 for the family and is covered for an additional 500% over medical aid rates – most other companies cover up to 500%

These are the costs that were charged whilst in hospital and which were subsequently submitted to the Gap cover provider.

Their invoice Medical Aid paid Gap / Shortfall
Obstetrician R18, 000 R3,704 R14,296
Hospital costs  R29,470  R29,470  N/A
Anesthetist R4,015 R1,540 R2,475
Pediatrician  R2,266 R1,216 R1,050
Pathologist R671 R671 N/A
R54,422 R36,601 R17,821

And that, folks, is why you need Gap cover.

Gap cover is about expecting the unexpected, and facing reality

Medical aid doesn’t always protect you from the things that you fear most – unplanned medical costs. The reason is simple. They compensate you for costs resulting from your hospitalization, but only up to an approved amount per ICD-10 code; and that’s it.

You’ll note that mom’s medical aid paid her hospital costs in full; that’s simply because hospitals generally charge 1 times medical aid scheme rates. Medical professionals, however, don’t – and this is generally where the gap arises.

We don’t like to think of the need for hospitalization other than for exciting things like childbirth, but one has to think of the possibilities around unplanned medical expenses and what this might mean for your wallet.


Finally, we’ll reiterate that although Gap Cover can feel like yet another cost being piled on top of your insurance and medical aid, it is a VITAL addition. Assume that ALL private medical professionals charge more than the hospital rate, because they all do.

Yours in health, financial and otherwise,

The Editors

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