Medical cover comes in various forms and structures, Comprehensive, Hospital Plan or Capitated plans. Most common types are a combination of a hospital plan and a savings account for day to day expenses. When savings are depleted, a self-payment gap will be created. After the gap has been filled by self payments, the medical aid recommences paying day to day claims until yearend. Importantly, all claims are paid and accumulated at medical aid tariff and may result in a bigger self- payment gap than advertised. The hospitalisation part of a medical aid normally covers the member at either 100%, 200% or 300% depending on your plan. Please note that this does not guarantee that accounts will be paid in full (100%), it means 100% of the medical aid tariff, hence, it is important to add Gap Cover.
Gap Cover covers the shortfall between what a doctor or specialist charges and what the medical aid tariff is in hospital.