30 May Understand how to claim from GapCover – your step-by-step guide to navigating medical shortfall claims

You’ve just come out of surgery and you’re focusing on recovery, until the hospital calls to let you know your medical aid didn’t cover everything. Cue confusion, stress, and the dread of unexpected medical bills.

That’s where GapCover comes in. It’s designed to help you manage medical aid shortfalls, those nasty gaps between what your healthcare provider charges and what your medical aid pays. In this guide, we’ll walk you through the GapCover claims process so you can claim medical aid shortfalls with confidence.

Why you might need to claim

Medical aid shortfalls are more common than you might think. If your doctor charges more than your scheme’s tariff (sometimes by over 500%), you could be left footing a hefty bill.

Real-world example:

A back fusion surgery cost one of our clients R87,633.53. The medical scheme only covered a portion, leaving a shortfall of R65,675.32. Without GapCover, the member would have had to pay this from their own pocket.
GapCover steps in to bridge that gap, giving you peace of mind and financial protection when you need it most.

When to submit a claim

Submit your claim after your medical aid has processed and paid their share from the risk portion, not savings. You have up to four (4) months to submit your GapCover claim.

Pro tip: If you have GapCover combined cover, you can confirm your benefits before your procedure, saving you the surprise later. Just send your authorisation to assessments@gaprisk.co.za. Our expert assessors will do a pre-assessment and provide you with peace of mind prior to your procedure.

How to claim: the step-by-step process

Step 1: Gather your documents

Prepare and complete the necessary GapCover claims form depending on your cover:

• GapCover / Combined Cover
• Elite Plan
• Primary Cover
  1. These aren’t small savings, they’re major stress-busters when medical needs hit.
  2. Copy of the doctor/s account(s). (Please contact the doctor/s for a copy.)
  3. Copy of the medical scheme claim statement, reflecting processing and payment of the applicable account/s.
  4. Authorisation confirmation from your medical scheme.
  5. Copy of the latest (not older than 3 months) medical scheme membership certificate.
  6. Should the bank details for payment of claims differ from the debit order bank details, proof of bank details must be provided in the form of a bank statement.

NB: Claims must be submitted to GapCover® within 4 months after the scheme payment date. NB: Claims cannot be processed until all the required documents have been received.

Step 2: Confirm your medical aid has paid from the risk portion.

If you have a savings account with your medical aid:

A medical aid has two money jars. Risk is the big, shared jar: everyone’s premiums fill it, and the scheme uses that pool to pay the benefits promised in your plan like hospital stays, certain GP visits, and more. This is only covered up to the annual limit the scheme sets. The smaller jar is your Medical Savings Account (MSA), funded by up to 25% of your premium and reserved for everyday costs like routine doctor visits or medicines that aren’t already covered from risk. When a claim is processed, check your statement: if your savings balance drops, the payment came from the MSA; if it doesn’t, the scheme paid from the risk pool.

If you don’t have a savings account with your medical aid:

All your claims are paid from risk.

Step 3: Submit your documents

Once you have all your necessary documents together, email your completed GapCover claims form and supporting documents to: claims@gaprisk.co.za.

Step 4: Wait for processing

GapCover claims are reviewed by GapRisk Administrators who is the Administrator of GapCover, underwritten by Western National Insurance. You’ll be contacted if there’s missing information. Once your claim is assessed:

• If valid, the shortfall is reimbursed to you.
• If there’s a problem, a team member will contact you to resolve it quickly.

Step 5: Payment is made directly to you.

If approved the payment will be made directly to the bank account that pays for the premium.

Pro tips for a smooth claim

• Make sure your contact details are current.
• Submit your claim as soon as your medical aid has settled their portion.
• Keep both digital and hard copies of all medical documents.

Testimonial:

A GapCover member on a 100% MSR plan underwent a colonoscopy costing R17,764.99. The member says, “My scheme paid R4,633.50, and then GapCover covered the shortfall of R13,131.49. Because of GapCover, I was saved from having to pay a large, unexpected bill.”

FAQs and common claim issues

Q: What if my medical scheme paid from savings?


A: GapCover won’t cover that. GapCover claims must be paid from the risk portion.

Q: Can I claim for GP visits?


A: No. GapCover only applies to in-hospital procedures.

Q: Can I claim for Prescribed Minimum Benefits (PMBs)?


A: Some GapCover plans offer limited cover for planned PMB admissions. Check your specific policy brochure.

Conclusion

We know that dealing with medical aid payment shortfalls can be stressful, that’s why we have streamlined our processes to ensure claiming from GapCover is easy and fast. If you follow the process and submit the correct documents, you will find the process to be easy and stress-free.

Need help with a claim or unsure what’s covered? Get personalised support here.

For more details or to sign up, visit GapCover.co.za.