GapCover® provides a benefit equal to the actual cost, limited to 5 times the medical scheme tariff, less payment for treatment received for services rendered by doctors and/or specialists while you are an in-patient in hospital.

Why do I need gap cover?

There is often a shortfall between what a medical scheme pays and the actual cost of a procedure or treatment, because service providers are entitled to charge more than the medical scheme rate. The shortfall then becomes the member’s responsibility and he/she will therefore need to have additional cover under these circumstances.

Some Hospital and Comprehensive Medical Plans offer cover at 100%, 150% or 200% of medical scheme rates for hospitalisation only, while the actual costs could be more than 500% of medical scheme rates.

GapCover® will cover the difference between what your medical scheme will pay and the actual cost of in-hospital doctor’s bills up to a maximum of 500% of medical scheme rates.

Listed below are four common medical procedures, with the combined charges of the specialist, anaesthetist and surgeon. The third column illustrates the payment shortfalls an individual on a standard, 100% of MSR, scheme option would experience.

Procedure Amount charged by service
Potential shortfall Incurred
(payable by GapCover*)
Natural child birth R8 308 R5 359
Caesarean section R15 343 R9 548
Appendectomy R19 156 R14 367
Tonsillectomy R7 528 R5 648

Can I use GapCover® in conjunction with any medical scheme?
Yes, this specific gap cover policy can be used in conjunction with any medical scheme registered in South Africa.

Does my GapCover® policy automatically cover co-payments?
No, a GapCover® policy does not cover co payments, but CoPay cover is available as an additional option. (Refer to the GapCover® application form).

What is the difference between GapCover® and CoPay cover products?
GapCover® will cover the difference between what your medical scheme will pay and the actual cost of in-hospital doctor’s bills, up to a maximum of 500% of medical scheme rates.

CoPay Cover is a product that will cover co-payments (the excess imposed and specified by your medical scheme) for procedures performed while you are an inpatient or an outpatient, and includes MRIs, CRs and Ultrasound scans.

Examples of listed Co-payments
Scheme Name Procedure Listed Co-Payment
Scheme A Gastroscopy in hospital R2 400
Scheme B Gastroscopy in hospital R3 400
Scheme B MRI/CT scans out of hospital R2 600
Scheme C MRI/CT scans in and out of hospital R1 800
Scheme C Hospital admission fee R1 000

What does the term “Combined cover” mean?
It is when you have chosen the GapCover® and CoPay Cover option together (combined).

Which companies are involved in GapCover®?
GapCover® is a product underwritten by Western National Insurance Company Limited and administered by Insuremed Administrators.

What is the medical scheme agreed rate?
The Council of Medical Schemes has specific codes for procedures and each code has a specific rate which is used as a guideline by medical schemes.

Are maximum annual limits applicable to GapCover®?
With the GapCover® policy, the maximum benefit payable per family is R1 000 000 per annum. This amount may be reviewed and changed from time to time.

What are the CoPay cover benefits?
CoPay Cover provides an incident limit of R10 000 limited to no more than three incidents/events per beneficiary per annum, and an overall annual limit of R50 000 per family.

What is classified as an incident or event?
A typical example of an incident or event might be as follows:
As the member of a medical scheme you suffer from persistent migraines; your medical practitioner requests and MRI (co payment of R1 800 applies); the MRI indicates bleeding on the brain and you are admitted to hospital for treatment (hospital admission fee of R1 000 applies); while receiving treatment a second MRI is done (co-payment of R1800 applies) which confirms that you need an operation.
The co-payments for both MRI scans and the admission fee will be seen as one event.

Why is a policy waiting period of 12 months imposed on conditions such as pregnancies, hysterectomies, tonsillectomies, grommets and adenoids?
With both GapCover® and CoPay Cover there is a waiting period imposed. This is because of the high level of anti-selection, so a waiting period of 12 months is imposed. These procedures and/or operations are covered from the 13th month onwards.

Are day-to-day services covered under the GapCover® policy?
No, normal visits to your GP or specialist, and auxiliary services on a day-to-day basis are not part of your GapCover® policy benefits.

What kinds of cancers are covered by GapCover®?
Benign tumours, borderline malignant, low malignant potential or non-invasive tumours, cervical dysplasia, intra-epithelial neoplasia, prostatic intra-epithelial neoplasia, leucoplakia and non-melanoma skin cancers are NOT covered as the treatment is provided out of hospital.
However, if the patient is admitted to a registered hospital for one of the above conditions and the ICD10 code confirms non-PMB treatment, GapCover® will review each case as an individual incident for possible payment subject to the administrator’s discretion.

Does this policy cover Prescribed Minimum Benefits (PMB)?
This GapCover® policy does not include benefits for PMB claims.

What is a PMB?
Prescribed Minimum Benefits (PMB) are a set of defined benefits to ensure all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable.
PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of:

any emergency medical condition;

a limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs);

and 25 chronic conditions (defined in the Chronic Diseases List).

What are the GapCover® policy exclusions?
Please refer to the policy document for a list of the standard policy exclusions.

What does GapCover® and CoPay Cover cost?
Please refer to the option premiums as indicated on the application form.

Are premium increases applicable to the GapCover® and CoPay Cover policies?
Yes, a premium increase may be applied on an annual basis.

Are there any additional costs?
No, intermediary and administration costs are included in your monthly premium for both GapCover® and CoPay Cover.

When will the first premium payments be debited?
The first premium will be debited within the first month of cover – see the Application form for debit order dates available.

Will the GapCover® premium be debited together with the medical scheme contribution?
No, GapCover® is a separate insurance product administrated by a different company.

What happens if the debit order date falls on a weekend or public holiday?
A debit order will be deducted on the next working day for GapCover® and CoPay Cover policies.

Who can apply for GapCover® and CoPay Cover?
GapCover® and CoPay Cover are both available to individuals who are members of a registered medical scheme, and are 70 years of age or younger.

What is the maximum age at which an individual can apply for GapCover®?
The maximum age at entry for the Western National GapCover® is 70.

Does my GapCover® policy stop when I turn 71?
No, the age limit is only applicable to new applicants. You will be covered as long as your policy is active.

Do I have to go for a medical examination to qualify for either GapCover® or CoPay Cover?
No, cover is available immediately, however underwriting will apply.

Who is covered by this policy?
GapCover® is provided for you, your spouse (or life partner) and all children registered as child dependants on your medical scheme.

Is a newborn baby covered under the GapCover® policy?
Yes, provided the baby is registered with the Administrator as a child dependant, within 30 days from date of birth.

Is a new spouse covered under the GapCover® policy?
Yes, provided that the spouse is registered with the Administrator as an additional dependant, within 30 days from date of marriage, and is not older than 70. Normal underwriting will apply.

Can I add more than one spouse to the GapCover® policy?
No, GapCover® allows for only one spouse, or life partner, to be registered as a dependant.

When will I receive my policy documents?
Your policy documents will be e-mailed to you within one week of registration of your application, provided that the application form is completed in full and no additional information is required. Original documents will be posted.

When will my GapCover® policy come into operation?
GapCover® will commence on the 1st day of the month for which your first premium is received. Terms and conditions apply.

When can I submit a GapCover® or CoPay Cover claim?
It is advisable to submit the GapCover® claim as soon as you have received the medical scheme payment. Claims submitted after 3 months of receipt of the payment will not be accepted.

What documents are required for the submission of a GapCover® claim?
A completed claim form, available on request, must be accompanied by detailed copies of all relevant doctors’ accounts, a clear copy of the hospital account,a detailed medical scheme statement reflecting the shortfall to the doctors’ charges, as well as a copy of your latest medical scheme membership certificate.

To whom will the GapCover® claim benefit be paid out?
All claim payments are made directly to the principal member.

Should any of my details or those of my dependants change, should it be communicated and what process do I need to follow to change these details on my GapCover® policy?
Yes, any changes must be communicated to the Adminsitrator of GapCover® within 30 days of the change. Please attach a copy of your updated medical scheme membership certificate as confirmation of changes to your dependants. Kindly contact the administrator for assistance with any changes.
Will new waiting periods be imposed on my GapCover® policy when I change from one medical scheme to another?

No. Although the GapCover® policy runs in conjunction with a medical scheme, the GapCover® waiting periods will not be affected when changing medical schemes.

When does the GapCover® policy end?
The policy will be terminated when the policyholder cancels the policy in writing, or when the policyholder allows the policy to lapse.

What process must I follow to cancel the policy?
To cancel the policy, the administrators must be given one calendar month’s notice, in writing, in order to cancel the policy. (A cancellation form is available on request.)

When will a GapCover® policy be cancelled automatically?
It will be cancelled automatically once three consecutive debit orders have not been met, as the policy will then be three months in arrears.

Can a GapCover® policy be reinstated?
Yes, within three months from date of cancellation the policy can be reactivated. If the policy is cancelled for a period longer than 3 months, a new application form must be completed.
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