Medical GAP | TD Admin Services

By: Td Administrative Services  11-11-2011
Keywords: Service Providers, Medical Aid

Gap Cover costs only R75, 00 per family per month. Gap and Gap Plus cover costs only R100, 00 per family per month.

What is Gap Cover?

GAP Cover is a product that was designed to cover the principal member and dependants (of a medical aid scheme) for out of pocket expenses that result from your medical aid paying less than you are being charged, by service providers, for an in-hospital procedure. The phenomena has, in recent years, become more prevalent as more and more medical practitioners are charging more than the benefits offered by the medical scheme.

The problem, simplistically, is that the medical aid industry, as a general rule, base their scale of benefits on a document produced annually by the Council of Medical Schemes (the National Health Reference Price List). Medical aids will make offerings of benefits based on one/two or three times these guidelines, however service providers (surgeons, anesthetists etc) are not bound to observe the guidelines set out in the NHRPL and it is common to see medical accounts reflecting as much as four times the NHRPL rates. This problem is highlighted by the following analysis of an actual claim:

Caesarian Charged NRPL Gap cover benefit
Pre op exam R 514.00 R 181.60 R 332.40
Caesarian R 753.00 R 264.70 R 488.30
Time R 1 380.50 R 485.21 R 895.29
Total R 2 647.50 R 931.51 R 1 715.99
Caesarian R 5 600.00 R 1 876.50 R 3 723.50
Assistant Fee R 1 800.00 R 616.28 R 1 183.72
Total R 7 400.00 R 2 492.78 R 4 907.22
Total Benefit R 6 623.21

As can be seen in this situation the total “Gap” between what the medical aid would pay and the actual amount outstanding amounted to R6 623.21. The Gap cover would pay out the difference between the service providers charges and the medical aid refund, to a maximum of three times the NHRPL.

Extended Benefit - Gap Plus

Most medical schemes now expect their members to pay a co-payment on admission to hospital, this amount varies but it could be as much as R2000.00. The Gap Policy has been extended to include this, and if you require cover for this contingency please indicate your intention on the application form.

Keywords: Medical Aid, Service Providers

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