Why do clients need Gap Cover?

Modified on Thu, 25 Apr 2024 at 09:06 AM

Gap cover serves as a crucial lifeline for clients encountering discrepancies between the costs of in-hospital procedures and the reimbursements provided by their medical schemes. When a medical scheme covers only a portion of the expenses incurred, Gap Cover steps in to bridge the divide, alleviating the financial strain on the individual. 

It’s imperative to grasp the value of Gap cover hinges on the coverage provided by the underlying medical scheme. If a particular procedure of code isn’t covered by the medical scheme, the Gap Cover would not extend its assistance, underlining the importance of comprehensive medical scheme selections. 

Consider the case of a middle-aged client enrolled in a comprehensive medical scheme, undergoing surgery for Acute Ischaemic Heart Disease – an ailment characterised by obstructed blood flow to the heart muscle due to blockage in a coronary artery. Following the procedure, the client was presented with a substantial bill totalling R274 573 for specialist and hospital fees. Despite the medical scheme settling only 40% of the bill, amounting to R110 933, the financial burden was significantly mitigated by the intervention of Gap Cover. The remaining R163 640 was promptly settled, allowing the client to focus on recuperation without the looming anxiety of financial distress. 

Even individuals enrolled in medical schemes boasting coverage at 200% of tariff may find themselves vulnerable to substantial financial shortfalls. Hence, Gap Cover emerges as an indispensable safeguard, ensuring peace of mind for individuals seeking comprehensive protection against exorbitant expenses associated with in-hospital treatments and procedures. 

Crucially, the necessity of Gap Cover transcends age demographics. While it may be commonly associated with older individuals, the evolving landscape of healthcare dictates its relevance across all age groups. Whether young or old, anyone seeking a seamless shield against unforeseen financial burdens in healthcare would be remiss to overlook the importance of Gap Cover. 


In essence, Gap Cover emerges as a beacon of financial security in the tangle of healthcare costs, providing a vital buffer against the uncertainties inherent in medical expenses. Its role in safeguarding individuals from the pitfalls of underinsurance underscores its status as an indispensable facet of comprehensive healthcare planning, ensuring that the focus remains steadfastly on healing and well-being, rather than financial difficulties. 

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