In South Africa, medical aid schemes often fall short when covering certain medical expenses. This is where gap cover comes in. PPS Gap Cover is designed to bridge the financial gap left by medical aids, ensuring you’re protected from unforeseen medical costs. This guide explores the benefits, coverage, and premiums of PPS Gap Cover in 2024, helping you make an informed decision.
What is PPS Gap Cover?
PPS Gap Cover is a health insurance policy that compensates for medical expense shortfalls when your medical aid only covers part of your treatment costs. Unlike medical aid, which is a comprehensive health insurance policy, gap cover specifically addresses the financial gaps left by your primary medical aid.
Coverage Overview
Premiums
PPS Gap Cover premiums vary based on age and family coverage:
- Primary Member under 55: R407.00 per month
- Aged 55 to 64: R504.00 per month
- Aged 65 and over: R633.00 per month
For family coverage:
- Family members under 65: R504.00 per month
- Family members 65 and over: R633.00 per month
Benefits
In-Hospital Coverage
PPS Gap Cover provides substantial in-hospital coverage:
- Doctor and Specialist Charges: Up to 500% of the medical scheme tariff (MST). It covers the shortfall between doctor/specialist fees and what the medical aid covers.
- Medical Aid Co-payment: Covers co-payments required by your medical aid for hospital admissions, scans, and procedures.
- Non-Network Co-payment: Provides cover for non-network hospital co-payments, up to R12,400 per claim per year.
Casualty and Emergency Treatment
- Accidental Injury Treatment: Up to R23,600 for treatment in a hospital’s casualty ward within 48 hours of the injury. Note that prostheses and post-treatment devices are not covered.
- Emergency Treatment for Children: Up to R2,650 per calendar year for after-hours emergency treatment for children under 11.
Oncology Treatment
- Co-payment Cover: Covers up to 25% of the costs when the annual cancer treatment limit is exceeded.
- Contribution to Costs: Provides 20% coverage for ongoing cancer treatment costs beyond the medical aid’s limit.
- Enhanced Coverage: Includes up to R25,600 for cosmetic breast reconstruction after a mastectomy due to breast cancer.
Dental and Out-of-Hospital Coverage
- Dental Shortfall: Covers up to R12,400 for dental hospital admissions and procedures, with a limit of one claim per year.
- Out-of-Hospital: Covers shortfalls on approximately 50 approved procedures, including surgeries and diagnostic tests, up to five times the medical aid tariff.
Enhanced Cancer Cover
- Enhanced Cancer Cover: Provides an additional R30,000 for unexpected costs related to a first-time cancer diagnosis of stage II and above. Coverage includes stage I prostate cancer with a Gleason score of 8 or higher. This benefit applies only if diagnosed after the 12-month waiting period.
Optional Extended Cancer Cover
- Extended Coverage: Available in amounts of R100,000 or R200,000. Premiums are R92.00 for R100,000 cover and R150.00 for R200,000 cover. This cover is valid until the policyholder turns 65. Pre-existing conditions are not covered in the first 12 months.
Advantages of PPS Gap Cover
- Comprehensive Coverage: Provides extensive coverage for in-hospital and out-of-hospital medical expenses, including high-cost treatments and surgeries.
- Family and Individual Options: Flexibility to cover both individuals and families, including dependents over 65.
- Enhanced Cancer Treatment: Strong coverage for cancer treatments, including additional support for cosmetic procedures post-mastectomy.
- Affordable Premiums: Premiums are competitively priced compared to the coverage provided.
Disadvantages of PPS Gap Cover
- High Premiums for Older Age Groups: Premiums increase significantly for those aged 65 and over, which may be a concern for some policyholders.
- Limited Coverage for Certain Treatments: Out-of-hospital dental procedures are not covered, and some prosthetic devices are excluded.
- Exclusion of Pre-existing Conditions: Extended cancer cover does not include pre-existing conditions during the first year.
Conclusion
PPS Gap Cover offers valuable protection against the shortfalls of medical aid schemes, with comprehensive in-hospital and out-of-hospital coverage. It is especially beneficial for individuals and families who seek additional financial security for high-cost medical treatments and surgeries. While premiums can be high, particularly for older members, the extensive coverage and benefits provided make it a worthwhile consideration for many South Africans. If you’re looking to enhance your medical aid coverage, PPS Gap Cover could be the solution you need.
