Hospital Bills Too High? How GAP Cover Bridges the Difference

There’s no feeling quite like it. You’ve just been through a stressful hospital stay, and you’re relieved it’s over. You believe your medical aid has taken care of everything. Then, a few weeks later, an unexpected bill lands in your mailbox. It’s from a specialist, and it’s for thousands of Rands—an amount your medical aid refused to pay.

Your heart sinks. How is this possible? You pay your medical aid premium every single month!

This shocking experience is all too common for many South Africans. It’s a painful gap between what we think our medical aid covers and what it actually pays. But you don’t have to be caught out. There’s a powerful solution that acts as your family’s financial shield: GAP Cover. It’s the key to making sure a health scare doesn’t turn into a financial disaster, making you feel truly unstoppable.

Why Your Hospital Bill is Higher Than Your Medical Aid Payout

Understanding why this "gap" exists is the first step to protecting yourself. It’s not because your medical aid is trying to trick you; it's because of how the system works.

1. The Medical Scheme Tariff: Your medical aid has a specific rate it will pay for any given in-hospital procedure. This is called the Medical Scheme Tariff, or scheme rate. Think of it as their price list, they might pay up to 100% of this rate.

2. Specialists Charge More: Here’s the problem. Specialists (like surgeons and anaesthetists) can charge whatever they like, while you’re in hospital. And very often, they charge three, to five times more than the medical scheme rate (500%). Your medical aid pays its portion for your procedure in-hospital, and you are left to pay the rest. That’s the gap!

3. Co-payments and Sub-limits: Many medical aid plans require you to pay a fixed amount upfront for certain procedures. This is a co-payment. It could be R2,000 for an MRI scan or R10,000 for a specific scope. Additionally, your plan might have a sub-limit, meaning it will only pay up to a fixed amount for procedures, leaving you to cover the rest.

4. Using a Non-network DSP: Medical aids have networks of Designated Service Providers (DSPs)—hospitals and doctors they have agreements with. If you use a hospital or specialist outside this network (sometimes you have no choice in an emergency!), your medical aid might pay less, leaving you with a bigger shortfall.

How GAP Cover Becomes Your Financial Champion

GAP Cover is designed specifically to tackle these problems. It works alongside your medical aid to take care of the bills that leave you exposed.

• Covers In-hospital Medical Expense Shortfalls up to R219 845: This is its main superpower! When your doctor or hospital charges 500% of the medical scheme rate for an in-hospital medical procedure and your medical aid only pays 100%, GAP Cover steps in to cover that 400% difference, up to your policy limits.

• Refunds Co-payments: That fixed co-payment you had to make for your hospital admission or scan? GAP Cover can pay that amount back into your bank account, up to the annual gap cover limit of R219 845

• Helps with Sub-limits: If your medical aid has a limit on what it pays for something, GAP cover can help pay the difference. Only for in-hospital expenses!

• Assists with Casualty Fees: If you have an accident and need to visit a hospital emergency room, GAP cover will help pay the facility fees that your medical aid might not pay for, up to R10 000 per person per year!

• Defined Oncology Benefits: For cancer treatment, GAP Cover can provide additional financial support when your medical aid’s benefits run out, helping with things like co-payments for treatment.

Real-Life Scenarios: How GAP Cover Saves the Day

Scenario 1: The Caesarean Section

A new mother has a C-section. The anaesthetist charges R8,000. Her medical aid only covers the medical scheme rate of R2,000.

• Without GAP Cover: She has to pay the R6,000 shortfall herself.

• With GAP Cover: She submits her bills, and her GAP Cover pays the R6,000 difference for her. She can focus on her new baby, not on debt.

Scenario 2: The Knee Scope

A weekend soccer player needs a knee arthroscopy. His medical aid requires a R5,000 co-payment upfront before the hospital will admit him.

• Without GAP Cover: That R5,000 is gone from his savings.

• With GAP Cover: After the procedure, he claims and gets the R5,000 co-payment refunded to him.

Scenario 3: The Emergency Appendectomy

Someone gets acute appendicitis while on holiday. They are rushed to the nearest hospital, which is not in their medical aid’s network. The surgeon charges well above the scheme rate.

• Without GAP Cover: They face a massive shortfall because the surgeon’s fees are high and they used a non-DSP hospital.

• With GAP Cover: The policy covers the specialist shortfall for in-hospital expenses, protecting them from a huge and completely unexpected bill, plus they can claim back up to R13 000 for the use of a non-network hospital.

The Simple Claim Flow: Who Pays What?

We believe in making things easy. Here’s how it works:

1. Your medical aid pays first. After your hospital stay, your medical aid pays its share, according to the medical aid rates it covers - directly to the doctors and hospital.

2. You get the shortfall bills. The specialists and hospital will send you the invoices for the amounts your medical aid didn't cover.

3. You submit to us. You send us those invoices along with the medical aid and doctors statements including the ICD-10 codes, showing what was paid.

4. We pay you. We assess your claim and pay the covered amount directly into your bank account. You can then settle with the specialists, feeling totally in control.

Your Pre-Procedure Checklist: Avoid Surprises!

For any planned hospital procedure, being prepared is your best defence.

• Get Quotes in Writing: Ask your surgeon and anaesthetist for a detailed quote before you book your surgery.

• Ask the Magic Question: Ask their reception, "What percentage of the medical aid rate do you charge?" This tells you how big the gap will be.

• Get Pre-Authorisation: Make sure your procedure is pre-authorised by your medical aid. Get the authorisation number.

• Use a network hospital where Possible: Check if your specialists and hospital are part of your medical aid’s Designated Service Provider network.

Unleash Your Unbeatable Peace of Mind!

Having medical aid is a great start, today, it’s often not enough to protect you completely. GAP Cover plays a crucial role as one of your financial safety nets. It’s an affordable way to ensure that when you need in-hospital medical care, your only focus is on getting better—not on the bills. It’s time to close the gap for good!

If you have any questions, we’re here to help - just call us on 0861 990 000 or discover the benefits of GAP Cover

Love, The Unlimited