The pitfalls and gaps of gap cover added to a hospital plan

QIs it normal for gap cover policies to cover you if you only have a hospital plan? Are there any lurking pitfalls to watch out for which might mean you are not covered? Anonymous medical — scheme member via e-mail.

AJill Larkan, head of health care at GTC, replies: You can take out a gap cover policy with any medical scheme option — the only prerequisite is that you are a member. However, you must remember that gap cover only tops up benefits your scheme already offers and only up to R157,000 per member per year in 2019, increasing to about R164,000 in 2020.

Hospital plans are more cost-effective medical aid options, designed to cater for the young and healthy. They typically cover you for hospital admissions only and exclude any out-of-hospital benefits except those prescribed by law which all schemes must cover, such as the 27 common chronic conditions.

This means your gap cover or shortfall policy will top up the hospital benefits offered by your scheme.

If your scheme option does not pay for expensive out-ofhospital treatment that you may require, for example rehabilitation after an accident, a gap cover policy will not fill that gap.

Some gap cover policies do offer additional stated benefits, such as that which covers treatment in a hospital emergency room that your scheme may not cover or lodge as a copayment. Copayments for expensive MRI or CAT scans raised by your medical aid can be claimed from some top-up plans.

Medical aids typically limit cancer treatment cover to a rand amount of say R200,000 or R400,000, and when this is exhausted charge a 20% copayment on any additional treatment. This additional 20% can be claimed from many topup plans.

Some insurers offer supplementary cover in the form of a lump sum on diagnosis of certain illnesses, but this cover is typically for a defined amount from a specified list of conditions and if your expenses or illness fall beyond those definitions, you are on your own.

Remember that you can upgrade or downgrade your medical scheme or top-up/gap cover policy option at the end of each year. Premiums for both change in January of each year.

Gap cover policies typically have general waiting periods that prevent you claiming in the first three months of the policy and in the first 12 months in respect of a condition you already have when you take out the policy.

Some insurers waive these waiting periods if you have existing gap cover.

IF YOUR SCHEME OPTION DOES NOT PAY FOR EXPENSIVE OUT-OF-HOSPITAL TREATMENT, A GAP COVER POLICY WILL NOT FILL THAT GAP