How to Submit Your Gap Cover Plan

Once you’ve made the decision that you need gap cover, you need to investigate your options. Gap cover is there to pay the shortfall between what the healthcare provider charges and your medical aid is prepared to pay.

Several service providers offer gap cover. Their products differ. Before choosing one, make sure you know what will and won’t be covered.

The gap cover claim process

  • Find out how much your medical aid will be paying.

You need to be familiar with how your medical aid pays healthcare professionals. Specifically, you need to know what your medical aid’s MST (medical scheme tariff) is. The healthcare provider will set an MST each year. It pays out 100%, 200% or even 300% of what the doctor charges. How much the medical aid pays depends on the scheme and which plan you’re utilising.

  • Find out how much your gap cover provider will be paying.

Once you know how much your medical aid is prepared will pay, examine the balance to work out how much you’ll be claiming from your gap cover provider. Look at your gap cover benefits to see how much you can expect to receive. Don’t assume that you will be reimbursed the full amount. There may still be a shortfall afterwards. That’s why it’s essential to know how your gap cover plan payouts are calculated.

Most gap cover providers do not automatically pay the full amount of the shortfall in your bill. Providers are now turning to what the medical aid pays and calculating their payment as a percentage of that. They might, for instance, payout double what the medical aid does. Higher tier plans payout five times what the medical aid does.

Look at it like this:

Total bill : R50,000
Medical aid : (R15,000)
Gap cover : (R30,000)

Remaining shortfall you will need to pay: R5,000.

This calculation is based on a gap cover provider that pays out double what your medical aid will. If you have gap cover that pays five times what the medical aid will, you won’t have an outstanding balance to pay. The medical aid will still pay out what it is supposed to, and the gap cover plan will pay the balance. You will not receive the amount remaining as a lump sum. It will merely mean that you have used less of your total annual gap cover benefit.

  • Make sure the provider covers the procedure.

Gap cover plans exclude certain procedures and expenses. Make sure that you aren’t trying to claim for something that will be declined. Go through the fine print of the policy to make sure you’re aware of the details.

  • Complete the necessary paperwork

Each provider has its own processes for making claims. It usually starts with a form that you need to complete. You will need to attach evidence of the claim to your form. This would normally take the form of an invoice or statement from the healthcare provider. You should be able to show how much the medical aid will be covering.

Each provider has its own processes. A claim might take a while to be taken care of. Providers receive hundreds of claims daily. The best way to ensure that everything runs smoothly is to have all the necessary paperwork ready. Follow up with your gap cover provider so that you can keep track of your claim.