By Michael Emery, Ambledown Financial Services Marketing Executive

While most consumers understand what gap cover is in principle, there are still a few questions that come up once they are in the process of investigating whether they need gap cover, and which product would best suit their needs. Some of the most common questions brokers encounter are answered below. 

• Is there a waiting period when joining? What happens if I am moving from one provider to another? 

Yes, most providers will impose a general three-month waiting period. This would not apply to valid claims resulting from an accident.

• What happens if I have a pre-existing condition?

If you have a pre-existing condition and you have received treatment or advice up to 12 months before joining Gap cover, your provider may impose a 12-month waiting period during which time you may not claim against this condition on your new policy. If you decide at some later date to upgrade or downgrade your policy and the new policy has new benefits, the provider may decide to apply a 12-month waiting period.

If you are moving from one gap cover provider to another gap cover provider, with materially similar benefits and the waiting period on the original policy hasn’t expired, the unexpired portion of the waiting period would apply to the new policy. Otherwise, there is no waiting period.

• What is excluded in gap cover?

Any procedure not covered or authorised by the medical scheme may not be claimed. Make sure that you check your policy for the cover provided.

It is very important to understand the exclusions, as well as the terms and conditions in your policy document. 

• Can I obtain gap cover for parents, adult children and grandchildren?

It all depends on the gap cover provider. Most gap cover provides cover for immediate family (the policyholder’s spouse and eligible children). Adult children would have to have their own gap cover policy in place, even though they may be financially dependent on the policyholder and registered as dependents on their medical scheme. 

Grandchildren will be covered only if they have been legally adopted or fostered. Different gap cover providers have different definitions for a family, so make sure you check how family is defined in your gap cover policy. 

• Is emergency treatment in Casualty included in gap cover?

Always remember that cover differs according to the gap cover provider, so you will need to check your policy or speak to your broker. Where cover is provided and an insured person goes to Casualty, their costs will generally be covered by the medical scheme (depending on your medical scheme option), according to the scheme’s benefits. If there is a difference between what the medical scheme pays and the casualty invoice, the policyholder may claim this amount. 

• Will my gap cover policy cover co-payments?

Please check your policy document or speak to your broker to check if your gap cover policy includes co-payment cover. If not, speak to your broker to discuss whether this is something you should consider.

• What can I do if I am unhappy with the claim assessment?

It is a legal requirement for insurers to include an escalation process when informing you of their decision when assessing a claim. This process includes an opportunity to question the decision with the insurer. If you are still not satisfied with the response, you may then escalate your complaint to the Ombudsman (details are provided in your policy document). In addition, the claims and escalation process will be detailed in your policy document.

In conclusion, gap cover has an important role to play in ensuring you and your family can access the right level of medical cover without suffering excessive financial consequences.

For more information and to find a gap cover solution to suit your specific needs, go to www.ambledown.co.za/gap-cover-series.