Will Your Medical Aid leave you with a Shortfall or Co-Payment in hospital?

Your medical aid does not guarantee that you won't have to pay money towards your medical costs!
Over many years of excessive medical inflation, the gap between what medical services cost and what a medical aid pays have increased.
Private providers are now charging up to 5 times the basic medical aid rate your plan may pay!
Some schemes now offer - more expensive plans - that pay at 2 or 3 times the medical aid rate.
But that is still not enough and the possible gap you could be liable for, can no longer be ignored.

Unfortunately South Africa is a violent country and the threat of you being hospitalised is very real.
Do not think, because you have medical aid you will not face a financial threat of short paid hospital costs - you can!
You really need to cover possible in-hospital shortfalls and co-payments that you may have to pay on certain procedures.

And this is the case with almost ALL MEDICAL AID PLANS.
Do you even know at what rate your scheme pays in-hospital specialists?

If you are a member of a medical aid and can get a Gap or Top Up plan, don't think twice - join TODAY!

gap cover

What is Top Up Cover?

Medical schemes pay in hospital costs at differing rates. At the beginning of a year all medical providers and medical schemes decide on the cost of a procedure.
That is known as the scheme (medical aid) rate. Schemes then pay at that rate.
If you use private providers, they can charge what they want - known as the private rate.
This can be 5 times more expensive than the medical aid rate!
So, medical aids now offer more expensive plans, that will pay up to 3 times their scheme rate, to help you with that claim shortfall. (Generally hospital and ward fees are charged at the scheme rate and are fully covered.) But these rates of payment are not sufficient to prevent a potential claim shortfall.

4 common hospital procedures, including specialist and anaesthetist fees.
You can clearly see the potential payment you would have if you are on a plan that pays medical aid rates in hospital.

gap cover

You also have financial threats of CO-PAYMENTS for certain procedures. More expensive plans have fewer co-payments.

co payment cover

Let's look at an example...
You need a hip replacement. Most medical aids pay ward and theatre fees in full, as these are billed at medical aid rates.
But specialist and other private providers can - and do - charge above this rate.
These specialists charge R 25,300.
Your medical aid pays R 8,423 of these costs.
You have to pay R 16,877! That's not going to help your recovery!

You have 2 options to address this threat.

1. You can use network providers who are linked to your medical aid, because they will charge what the plan pays. So, you should never experience an in-hospital claim shortfall.

2. Or, best of all, join a Top Up/Gap plan that will pay any in hospital shortfall and co-payment.

gap coverNow, YOU CAN CONSIDER A LOWER COST MEDICAL AID PLAN, THAT PAYS AT MEDICAL AID RATES, because you are safe in the knowledge you are protected against high hospital costs!
Yes, your Top Up will make good on any shortfalls or co-payments you have, up to a legislated maximum of R 157,000 per family, per year.
Every medical ascheme member should have an insurance-based Top up plan. It is a vital part of having full in-hospital cover!
These are totally separate products to a medical aid and will work with any medical aid.

Plans also offer cover for other cost your medical aid may not pay in full like:

  1. The use of a non-designated Hospital which results in a co-payment.
  2. Charges above any sub-limit imposed for defined surgical/medical treatments (EG. Internal Prosthesis) received whilst as an in-patient and/or out-patient.
  3. A combined capped amount for radiology and pathology services where your available out-of-hospital benefits are depleted.
  4. Enhanced private oncology treatment, once the sub-limits are reached and/or co-payment happen. (Incl. in-hospital expenses, biological drugs, in-and-out patient radiotherapy or chemotherapy).
  5. Cover for consumable shortfalls on disposable items.
  6. Casualty Benefit The cost of a medical or a surgical procedure following an emergency in a hospital casualty unit, where such costs were not met by your medical aid. (Orange and red triage)
  7. Trauma counselling.
  8. R 10,000 Cancer Lump Sum Benefit (Exclusion: Pre-existing Cancer and Skin cancer) - Stage 2 and higher, when diagnosed.
  9. R 10,000 per insured life for Accidental Death
  10. International Travel Cover
  11. 12-months Medical Scheme Premium Waiver following the death or the total and permanent disability of the Principal Member.

Please note that no day-to-day expenses are covered by Gap plans.
Also, that if your medical aid would never have paid for a claim - in terms of their rules - neither will the Gap plan.
Gap/Top up is a completely separate product to your medical aid.

gap cover

What is CoPay Cover?

In order to contain costs, medical aids are increasingly imposing co-payments for treatments and procedures, like MRI, CT, ultrasounds, scopes, prosthetics and scans.
These are amounts that need to be paid to the hospital/day clinic/radiologist before undergoing certain procedures.
Again, more expensive plans have fewer co-payments.

You pay a portion of the costs for procedures and your medical aid pays the rest. This is your co-payment.

CoPay will pay your co-payments for procedures performed in-hospital as well as some specified out-patient procedures including MRI, CT and ultrasound scans.

There are many of these plans available and they will cover most medical aid shortfall and co-payments, but this one is the most comprehensive for the price!

There are treatments that Gap Cover will not pay for like:

  • Ward costs in a hospital or step-down facility.
  • Upgrades to a private room
  • Pre-admission consultation costs
  • Medication (both in-hospital and take-home)
  • External prostheses (an artificial breast or a prosthetic leg)
  • External appliances, such as wheelchairs or crutches
  • Routine medical examinations, such as ultrasounds
  • Home or private nursing
  • Extra costs related to weight/BMI-related procedures
  • Mental health disorders, transportation costs (such as in an ambulance)
  • Out-of-hospital dental treatments
  • Cosmetic procedures
  • Costs incurred for treatment by a non-designated service provider (determined by your medical scheme)
  • Co-payments for any procedure for which you are in a waiting period.
  • Premiums from R 324 per family, per month for a very valuable plan!








    The plan works with any medical aid!
    Enhance your cover without having to change from your medical scheme!

    Note: Benefits are plan dependent.
    It is important to note that this product is specifically designed to help you meet the private tariffs charged by doctors, anaesthetists, radiologists, physiotherapists and specialist surgeons, for in-patient treatment.
    It does not cover the actual cost of the hospitalisation.
    A standard 3 month waiting period is applicable from date of inception to policy, and pre-existing conditions may be excluded for minimum 12 months.
    There is a total exclusion for any pre-diagnosed cancer and 12 month maternity exclusion. Terms and conditions do apply.

    With this cover, YOU will NEVER fear the pressure of financial shortfalls in the unfortunate event of hospitalisation.

    You owe it to yourself and your family to investigate these Top Up and Gap Cover Cover policies!


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