28 Nov When does GapCover not kick in? Understanding exclusions and waiting periods

Covering medical shortfalls shouldn’t drain your pockets. That’s why GapCover exists. It steps in when your medical aid doesn’t fully cover the costs charged by specialists and hospitals. It bridges the “gap” between what your medical aid pays and what the specialist charges.

When GapCover doesn’t pay, you deserve to know why. Many people assume it covers everything their medical aid doesn’t. This is not the case. GapCover only helps with qualifying claims for shortfalls that occur while you are in hospital. However, GapCover includes limited out of hospital benefits.

Let’s talk real numbers. These are average amounts charged by private practitioners and what you could be paying out-of-pocket without extra cover

What GapCover doesn’t typically cover

While GapCover is a great backup, knowing what isn’t covered is just as important as knowing what is.

Day-to-day medical expenses

GapCover does not cover day-to-day medical costs like:

• GP (General Practitioner) visits
• Prescriptions and chronic medication
• Over-the-counter medicines

These are considered “out-of-hospital” services and fall under your medical aid’s day-to-day benefits. If you run out of savings or don’t have a plan that covers these, unfortunately, GapCover won’t come to the rescue.

Cosmetic procedures

If you’re thinking about getting a nose job or laser eye surgery, GapCover won’t help unless it’s reconstructive surgery, which includes:

• Accidental injury that needs reconstructive work
• Cancer treatment, such as breast reconstruction
• A procedure that a healthcare professional deems medically necessary

Experimental and unapproved treatments

If a treatment isn’t widely accepted or approved by medical authorities, like the Health Professions Council of South Africa, GapCover won’t pay for it. This includes:

• Alternative therapies (homeopathy, acupuncture)
• Experimental cancer treatments not backed by clinical trials
• Any procedures not covered by your base medical aid

Elite also includes enhanced benefits for specialised procedures (like spinal or joint surgeries), helping you avoid those unexpected bills that often follow major operations.

Waiting periods: Why you can’t claim immediately

One of the more frustrating realities of GapCover is waiting periods. These are intentional delays before you can claim on certain benefits.

General waiting periods

GapCover providers impose a three-month general waiting period when you take out a new policy. During this time, you can’t claim for anything. This includes accidents or new diagnoses. It’s essentially a settling-in period to prevent “just-in-time” signups.

Pre-existing conditions

If you already have a medical condition, like diabetes, back problems, or heart disease expect a 12-month waiting period before any claims related to that condition are accepted. For example, you are:

• Diagnosed with gallstones before taking out GapCover? You can’t claim for related surgery for at least a year.
• Already pregnant when you signed up? GapCover won’t pay for the delivery or complications.

It’s a hard pill to swallow, but it protects insurers from sudden high-cost claims from people who already know they need treatment.

Pregnancy waiting periods

Pregnancy is considered a pre-existing condition, so if you’re already pregnant when signing up, GapCover won’t cover related costs. This includes elective C-sections at a non-designated service provider routine check-ups and tests.

However,  GapCover Elite covers some pregnancy shortfalls. A tip? Join before you fall pregnant. If you do, you can avoid the 12-month waiting period.

Plan ahead and protect your cover

GapCover is great when doing what it’s designed to do: help you avoid paying thousands of rands out of your pocket for in-hospital treatments. It’s not a magic card that pays for every medical expense, though. Know what isn’t covered, so you can plan well and avoid added frustration during stressful times.

Waiting periods also matter a lot. If you’re managing a chronic illness, don’t wait until the last minute to sign up. The earlier you join, the sooner you’re protected.

Compare or upgrade your cover today.