Medical aid and gap cover in retirement

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Guest contributor: Sue Torr from Crue Invest

The difference between what your medical specialist charges and what your medical aid covers – known as the ‘gap’ – can be unaffordable to the average person. This is where gap cover can play an important role in your overall portfolio, especially in retirement where healthcare costs tend to escalate quickly. With a vast array of gap cover options available, it may be difficult to decide what form of cover to put in place. This article unpacks the mechanics of gap cover and what to look for when choosing a benefit.

Higher risk with age 

As a retiree, your age will be a determining factor when selecting gap cover as it directly impacts your premiums and eligibility. Some gap cover providers have a cut-off age of 60 or 65 when it comes to new members, while other providers have no age limit. Many providers structure their premiums according to the age of the member, using age brackets of 55 and younger, 56 – 64 years, and 65 years plus – with the oldest age group paying considerably higher premiums as a result of the greater risk they pose. 

Benefits to consider

In the past few years, gap cover benefits have evolved to include a range of enhanced benefits. For instance, some gap cover policies cover the costs of upfront hospital co-payments, outpatient kidney dialysis, and procedures performed in day clinics. Many gap cover providers offer once-off lump-sum benefits if a member is diagnosed with cancer or a heart condition, accesses casualty or trauma, or in respect of internal prostheses such as a knee replacement. Other useful benefits to look out for include lump sum cover for accidental injury or death, accidental dentistry cover, and cover for medical treatment received when travelling internationally. Scopes and scans, which are normally performed on an out-patient basis, can be high-cost items (particularly MRI and CT scans), and as such, many gap cover policies provide benefits for these.

Not everything is covered

As is the case with medical aid, gap cover policies come with certain exclusions and waiting periods, and it is important to familiarise yourself with these before signing up. Most gap cover providers apply a general waiting period of three months before a member can claim benefits. They will generally also apply a 12-month waiting period for pre-existing conditions. Exclusions refer to certain procedures and treatments that will not be covered by your gap cover. These typically include elective cosmetic surgery, specialised dentistry, external prostheses, obesity and bariatric surgery, sleeping disorders, stem cell harvesting or treatment, or attempted suicide. Your gap cover provider should provide you with a detailed list of these exclusions in advance so that you are aware of what treatments and procedures you cannot claim for.

What’s not covered?

When deciding on a suitable gap cover policy, the first step should be to determine exactly what in-hospital benefits are offered by your medical aid. Then look for a gap cover policy that addresses the shortfalls. Keep in mind, however, that your gap cover is not designed to cover treatment for Prescribed Minimum Benefits (PMBs). Your medical aid is required by law to cover the cost of PMBs).

Because of the varying number and types of gap cover policies available, it is often difficult to do a comparative benefit and premium analysis. It may be worth seeking advice from an independent healthcare advisor before selecting. There are also some very useful gap cover comparison tools online that you can use to do your research (see below).

The most important thing to stress is that gap cover is something you should definitely consider to ensure that you’re covered for any health problems that could arise. 

Hippo: Compare Medical Gap Cover Quotes

Medical Aid Gap Cover Online

Retire blog

Saving for retirement is the biggest investment most of us will ever make. Sadly, it can also be very complicated. In this monthly blog, Carina Jooste responds to common retirement questions, ranging from which products are best suited to different circumstances to efficient tax treatments.

Carina is currently on maternity leave.