By Michael Emery, Marketing Executive at Ambledown Financial Services

Gap cover plays an important role in mitigating the impact of rising medical expenses but there are certain things it doesn’t cover.

In a recent radio interview, I was asked an important question: What isn’t included in Gap cover? As always, the devil is in the detail, and so what I want to do in this article is highlight what these exclusions are so that those with Gap cover understand exactly what their position is.

Knowledge really is power in the medical insurance world!

Before we look at Gap cover exclusions, it’s worth reminding ourselves that Gap cover is not a substitute for membership of a medical scheme and the cover is not the same as a medical scheme — in fact, Gap cover is only available to members of a medical scheme. As its name suggests, it is designed to limit the out-of-pocket medical expenses not covered in full by the medical scheme. Gap Cover products are generally designed to cover major medical events in hospital and specific out-patient treatment and procedures. They are not designed to cover shortfalls in your day-to-day medical expenses.

That clarified, let’s look at those instances where Gap cover is excluded.

The first instance relates to the normal exclusion periods when an individual takes out Gap cover. A general 3 months waiting period is applied and a 12 months pre-existing condition waiting period is also applied. The Gap cover will exclude an incident, even though it falls within the scope of the policy, if it relates to treatment or advice received in the 12 months prior to the policy coming into effect. This exclusion is only valid for the first 12 months of the Gap cover policy. It is important to note that claims as a result of an accident are covered from the inception of the policy and are not subject to any waiting periods. Remember to always check your policy document as exclusions are dependent on your Gap cover provider.

A matter of individual choice

In the interests of keeping premiums low for the consumer, there is a range of exclusions broadly relating to conditions that are arguably within the control of the insured. These are obesity, cosmetic surgery, suicide, alcohol and drug abuse and addiction, as well as routine procedures that are purely diagnostic and that are objectively not related to a health impairment.

The latter exclusion is clearly aimed at diagnostic expenses incurred purely as a precaution – of course, diagnostic procedures prompted by a health condition are covered depending on your Gap provider. One could also point out that many key precautionary diagnostic procedures, such as cholesterol and blood pressure tests, would generally be covered from your Medical Savings Account. As always, individuals need to check the precise details with their medical scheme.

There are a range of treatments that are excluded from most Gap cover policies; some already mentioned above. They include cosmetic surgery, drug and alcohol addiction, suicide and most mental conditions, including depression, insanity, mental or mental stress, psychotic / psychoneurotic disorders, behavioural and neurodevelopmental disorders. Typically, treatments and investigations relating to artificial insemination or hormone treatment for infertility are not eligible for Gap cover. However, some of these conditions are covered by the medical scheme.

Other exclusions

There are a range of exclusions related specifically to medical procedures that need to be understood by policyholders.

It goes without saying that any expenses that are covered by the underlying medical scheme, such as Prescribed Minimum Benefits, are not covered by Gap cover as there should be no shortfall. The Prescribed Minimum Benefits are conditions gazetted by the Minister of Health and that medical

schemes have to cover in full. They include emergency medical assistance, 271 medical conditions and 26 chronic conditions.

All fees strictly related to hospitalisation are generally excluded. These are ward and theatre fees, medicines, costs for materials such as gloves and the like, and any other hospital expenses. But the fees charged by specialists such as surgeons and anaesthetists do qualify for Gap cover – this is vital because the gap between what medical schemes pay and specialists actually charge is particularly wide. As always though, the details will change from policy to policy, so it is important to establish exactly what the details in your policy are. .

All of this can seem daunting at first, but there is no getting round it: it is a complex area. Spend some time reading through your policy document, discuss it with your broker and compare it with what your medical scheme covers to get a big-picture understanding.