How GapCare works

Your medical scheme must normally assess the healthcare claim first. If the scheme pays only part of an eligible claim, GapCare may cover some or all of the remaining shortfall, subject to the selected option, policy rules, waiting periods, annual limits and benefit-specific limits.

• You must remain a member or dependant of a registered medical scheme.
• Cover applies only to benefits included in your selected GapCare option.
• Pre-authorisation and network rules set by your medical scheme still apply.
• The policy schedule and current policy wording determine the cover that applies to you.

Available GapCare options

The three options provide different levels of cover. The premiums below reflect the supplied product material and may change. Confirm the current premium and benefits before applying.

Benefits that may be included

Depending on the selected option and the circumstances of the claim, GapCare may provide cover for the following benefits.

• In-hospital specialist shortfalls when an eligible specialist charges more than the medical scheme tariff.
• Co-payments and deductibles required by the medical scheme for certain eligible procedures.
• Cancer treatment shortfalls for approved treatment within the medical scheme oncology programme.
• Out-of-network hospital co-payments including unlimited eligible admissions at Netcare facilities and limited cover for one qualifying admission outside Netcare facilities per insured person each year.
• Charges above selected sub-limits for specified in-hospital procedures and facilities, subject to the policy limit.
• Emergency department treatment for eligible shortfalls and specified out-of-pocket costs arising from the initial treatment of a medical emergency.
• Maternity and out-of-hospital specialist benefits on GapCare 300+ and GapCare 500+, subject to the relevant benefit rules.
• Additional support benefits which may include trauma counselling, accidental death or disability benefits, a premium waiver and the GapCare Emergency Booster.

Waiting periods and limits

Waiting periods may apply when you take out gap cover for the first time. These can include a three-month general waiting period and twelve-month waiting periods for pre-existing conditions, pregnancy and childbirth, or certain non-emergency procedures. Different rules may apply if you move from another gap cover product with a break of less than three months.

The supplied product information states an overall annual limit of R212 000 per insured person, with separate limits for some benefits. Limits are reviewed and can change. Always refer to your current policy schedule and policy wording before treatment or submitting a claim.

How to submit a claim

1. Submit the claim to your medical scheme and wait for it to be processed.
2. Gather the healthcare provider statement showing the relevant diagnosis and procedure codes.
3. Include the medical scheme statement showing what was paid or declined and any reason codes for the shortfall.
4. Include proof of payment if you paid the provider directly, together with the banking details required for reimbursement.
5. Submit the completed claim and supporting documents online, through the Netcare app or by email to gapclaims@netcareplus.co.za.

Claim deadline Claims must be submitted within 180 days of the treatment, procedure or hospital admission. Claims received after this period may not be payable.

Common reasons a claim may not be paid

• The medical scheme did not process the claim first.
• The relevant policy or benefit limit has been reached.
• The event occurred during an applicable waiting period.
• Required medical scheme pre-authorisation or network rules were not followed.
• The treatment took place outside South Africa.
• The service should have been covered by the medical scheme or is not included in the GapCare policy.

This list is not exhaustive. Benefit-specific exclusions and the full general exclusions in the current policy wording also apply.

Applications and policy support

You can apply online or speak to your broker. You will usually need your South African identity number, banking details, dependant details, medical scheme option and information about previous gap cover.

• NetcarePlus service centre 0860 101 151
• Policy and service queries servicecentre@netcareplus.co.za
• Claims gapclaims@netcareplus.co.za
• Complaints complaints@netcareplus.co.za
• Specialist appointment service Netcare appointmed on 0860 555 565

Important information

This article provides a general overview and does not replace your policy schedule or policy wording. Eligibility, waiting periods, exclusions, benefit limits and claim outcomes depend on the terms that apply to your policy and the details of the claim.

FAQs

What is NetcarePlus GapCare?

NetcarePlus GapCare is an insurance product that may help eligible medical scheme members cover certain shortfalls between what their medical scheme pays and what a private healthcare provider charges. It does not replace medical scheme membership.

Who can apply for GapCare?

You must normally be a member or dependant of a registered South African medical scheme. Eligibility is subject to the applicable policy terms and underwriting requirements.

Do I still need medical scheme membership?

Yes. You must remain an active member or dependant of a registered medical scheme for GapCare cover to apply.

How does GapCare work?

Your medical scheme must normally assess the healthcare claim first. If the scheme pays only part of an eligible claim, GapCare may cover some or all of the remaining shortfall. Payment depends on your selected option, policy rules, waiting periods, exclusions and benefit limits.

Does GapCare cover every medical expense?

No. GapCare only covers eligible benefits included in your selected option. It does not cover every amount that your medical scheme declines or does not pay.

What GapCare options are available?

There are three options:

• GapCare: Eligible in-hospital specialist shortfalls of up to an additional 500% of the medical scheme tariff, together with core shortfall benefits and emergency support. The listed monthly premium is R345.

• GapCare 300+: Eligible in-hospital specialist shortfalls of up to an additional 300% of the medical scheme tariff, with maternity and eligible out-of-hospital specialist benefits. The listed monthly premium is R410.

• GapCare 500+: Eligible in-hospital specialist shortfalls of up to an additional 500% of the medical scheme tariff, with maternity and eligible out-of-hospital specialist benefits. The listed monthly premium is R450.

Premiums and benefits may change. Confirm the current information before applying.

What is a medical scheme tariff?

A medical scheme tariff is the rate your medical scheme uses when assessing a healthcare claim. A specialist may charge more than this rate, creating a shortfall that GapCare may cover if the claim is eligible.

What is meant by “up to an additional 500%”?

This refers to the maximum level of eligible specialist shortfall cover relative to the medical scheme tariff. It does not mean every claim will be paid at 500%. The amount payable depends on the provider’s charge, the amount paid by your medical scheme and the applicable policy limits.

Does GapCare cover in-hospital specialist shortfalls?

Eligible in-hospital specialist shortfalls may be covered when a specialist charges more than the medical scheme tariff. The level of cover depends on your selected GapCare option and the applicable policy rules.

Does GapCare cover out-of-hospital specialist visits?

Eligible out-of-hospital specialist shortfalls may be covered under GapCare 300+ and GapCare 500+. Benefit rules and limits apply.

Does GapCare include maternity benefits?

Maternity benefits may be included with GapCare 300+ and GapCare 500+, subject to the relevant waiting periods, eligibility requirements and benefit limits.

Are co-payments and deductibles covered?

Certain co-payments or deductibles required by your medical scheme for eligible procedures may be covered. This depends on the procedure, your selected option and the applicable policy terms.

Does GapCare provide cancer-related benefits?

It may cover certain eligible cancer-treatment shortfalls where the treatment has been approved under the medical scheme’s oncology programme. Policy rules and benefit limits apply.

Are medical emergencies covered?

GapCare may cover eligible shortfalls and specified out-of-pocket costs arising from the initial treatment of a qualifying medical emergency. Refer to the current policy wording for the definition of an emergency and the applicable limits.

Does GapCare cover treatment outside South Africa?

Treatment received outside South Africa is generally not covered under the supplied product information. Refer to the current policy wording for the full territorial restrictions.

Must I obtain pre-authorisation?

You must follow any pre-authorisation and network requirements imposed by your medical scheme. GapCare does not replace these requirements, and a claim may not be paid if they were not followed.

Are there waiting periods?

Yes, waiting periods may apply when taking out gap cover for the first time. These may include:

• A three-month general waiting period.

• A twelve-month waiting period for pre-existing conditions.

• A twelve-month waiting period for pregnancy and childbirth.

• A twelve-month waiting period for certain non-emergency procedures.

Different rules may apply when moving from another gap-cover product with a break in cover of less than three months.

Is there an annual benefit limit?

The supplied product information states an overall annual limit of R212,000 per insured person. Some individual benefits may have separate limits. Limits can change, so consult your current policy schedule and policy wording.

How do I submit a GapCare claim?

First submit the healthcare claim to your medical scheme and wait for it to be processed. You can then submit the GapCare claim with the required supporting documents online, through the Netcare app or by emailing gapclaims@netcareplus.co.za.

What documents are required for a claim?

You may need to provide:

• The healthcare provider’s statement, including the relevant diagnosis and procedure codes.

• The medical scheme statement showing what was paid or declined.

• Any reason codes explaining the shortfall.

• Proof of payment if you paid the provider directly.

• The banking details required for reimbursement.

• Any additional documents requested during the claim assessment.

How long do I have to submit a claim?

Claims must be submitted within 180 days of the treatment, procedure or hospital admission. Claims submitted after this deadline may not be payable.

Why might a claim not be paid?

Common reasons include:

• The medical scheme did not process the claim first.

• The treatment or benefit is not covered by the selected policy.

• A waiting period applies.

• A policy or benefit limit has been reached.

• Medical scheme pre-authorisation or network requirements were not followed.

• The treatment took place outside South Africa.

• Required claim documents were not provided.

This is not an exhaustive list. All benefit-specific and general policy exclusions also apply.

Does submitting a claim guarantee payment?

No. Every claim must be assessed against the selected option, policy wording, policy schedule, waiting periods, exclusions and available benefit limits.

How can I apply for GapCare?

You can apply online or speak to your broker. You will usually need your South African identity number, banking details, dependant information, medical scheme details and information about any previous gap cover.

Who can I contact for help?

• NetcarePlus service centre: 0860 101 151

• Policy and service queries: servicecentre@netcareplus.co.za

• Claims: gapclaims@netcareplus.co.za

• Complaints: complaints@netcareplus.co.za

• Netcare appointmed specialist appointment service: 0860 555 565

Where can I find the full policy information?

Your policy schedule and current policy wording are the authoritative sources for your cover. They explain the applicable eligibility requirements, waiting periods, benefits, limits and exclusions.