GapRisk Administrators
2.6|29 reviews
FA
FAROUK A
1 reviews | Active since Member
19 Dec 2025, 14:06
Worst Gap Cover Ever
Worst gap cover ever. Almost a **** . All they know is how to reject claims and then blame the medical aid for not covering it properly. What is the point then of gap cover. I think they don't understand there offering well at all. Going to the Ombud. I need to change to a gap cover product that works, as this one clearly doesn't. They find every reason they can to not pay claims.
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Replies (53)GapRisk Administrators's replyOfficial
22 Dec 2025, 10:55Good day, Mr Aboobaker
Thank you for your complaint. All feedback is valuable to us.
Our Claims Manager had tried to contact you this morning, and followed up with an email.
We've reviewed your complaint, and find the following:
GapCover is a short-term insurance product and is therefore prohibited to fund services which are not funded by the medical scheme - it is a supplemental insurance product, not an additional medical scheme benefit.
The reason for the repudiation is because your medical scheme repudiated funding towards tariff codes 0151, 0023 and 0034. GapCover provides cover where the specialist charges above the medical scheme rate, that means that the medical scheme must fist pay their scheme rate in order for GapCover to calculate the charges between scheme rate and the doctor’s rate. If we take tariff code 1461 into consideration, the provider charged 204.01% of scheme rate, the shortfall between the charged amount of R1093.90 and the scheme rate of R536.20 resulted in the shortfall of R557.70 which enjoys cover. We urge all our clients to please carefully review their policy documents in order to understand our product prior to submitting claims that do not qualify for benefits. We also urge you to make use of our pre-assessment service (free), where you submit your pre-auth in order for us to pre-assess and advise on possible issues such as non-dsp, etc.
I would recommend that you speak to your medical scheme to determine why they are not funding your procedure.
Wishing you and yours a wonderful festive season and prosperous New Year.
Kind regards,
The GapCover / GapRisk Team
Thank you for your complaint. All feedback is valuable to us.
Our Claims Manager had tried to contact you this morning, and followed up with an email.
We've reviewed your complaint, and find the following:
GapCover is a short-term insurance product and is therefore prohibited to fund services which are not funded by the medical scheme - it is a supplemental insurance product, not an additional medical scheme benefit.
The reason for the repudiation is because your medical scheme repudiated funding towards tariff codes 0151, 0023 and 0034. GapCover provides cover where the specialist charges above the medical scheme rate, that means that the medical scheme must fist pay their scheme rate in order for GapCover to calculate the charges between scheme rate and the doctor’s rate. If we take tariff code 1461 into consideration, the provider charged 204.01% of scheme rate, the shortfall between the charged amount of R1093.90 and the scheme rate of R536.20 resulted in the shortfall of R557.70 which enjoys cover. We urge all our clients to please carefully review their policy documents in order to understand our product prior to submitting claims that do not qualify for benefits. We also urge you to make use of our pre-assessment service (free), where you submit your pre-auth in order for us to pre-assess and advise on possible issues such as non-dsp, etc.
I would recommend that you speak to your medical scheme to determine why they are not funding your procedure.
Wishing you and yours a wonderful festive season and prosperous New Year.
Kind regards,
The GapCover / GapRisk Team
Best regards,
GapRisk Administrators's reply22 Dec 2025, 10:55
Official
Good day, Mr Aboobaker
Thank you for your complaint. All feedback is valuable to us.
Our Claims Manager had tried to contact you this morning, and followed up with an email.
We've reviewed your complaint, and find the following:
GapCover is a short-term insurance product and is therefore prohibited to fund services which are not funded by the medical scheme - it is a supplemental insurance product, not an additional medical scheme benefit.
The reason for the repudiation is because your medical scheme repudiated funding towards tariff codes 0151, 0023 and 0034. GapCover provides cover where the specialist charges above the medical scheme rate, that means that the medical scheme must fist pay their scheme rate in order for GapCover to calculate the charges between scheme rate and the doctor’s rate. If we take tariff code 1461 into consideration, the provider charged 204.01% of scheme rate, the shortfall between the charged amount of R1093.90 and the scheme rate of R536.20 resulted in the shortfall of R557.70 which enjoys cover. We urge all our clients to please carefully review their policy documents in order to understand our product prior to submitting claims that do not qualify for benefits. We also urge you to make use of our pre-assessment service (free), where you submit your pre-auth in order for us to pre-assess and advise on possible issues such as non-dsp, etc.
I would recommend that you speak to your medical scheme to determine why they are not funding your procedure.
Wishing you and yours a wonderful festive season and prosperous New Year.
Kind regards,
The GapCover / GapRisk Team
Thank you for your complaint. All feedback is valuable to us.
Our Claims Manager had tried to contact you this morning, and followed up with an email.
We've reviewed your complaint, and find the following:
GapCover is a short-term insurance product and is therefore prohibited to fund services which are not funded by the medical scheme - it is a supplemental insurance product, not an additional medical scheme benefit.
The reason for the repudiation is because your medical scheme repudiated funding towards tariff codes 0151, 0023 and 0034. GapCover provides cover where the specialist charges above the medical scheme rate, that means that the medical scheme must fist pay their scheme rate in order for GapCover to calculate the charges between scheme rate and the doctor’s rate. If we take tariff code 1461 into consideration, the provider charged 204.01% of scheme rate, the shortfall between the charged amount of R1093.90 and the scheme rate of R536.20 resulted in the shortfall of R557.70 which enjoys cover. We urge all our clients to please carefully review their policy documents in order to understand our product prior to submitting claims that do not qualify for benefits. We also urge you to make use of our pre-assessment service (free), where you submit your pre-auth in order for us to pre-assess and advise on possible issues such as non-dsp, etc.
I would recommend that you speak to your medical scheme to determine why they are not funding your procedure.
Wishing you and yours a wonderful festive season and prosperous New Year.
Kind regards,
The GapCover / GapRisk Team
Best regards,