Medical Gap Cover

Medical Gap Cover is a separate policy that helps cover the shortfall between what your medical scheme pays and what providers charge.

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Already on medical aid? You’ll still need gap cover

Understanding Medical Gap Cover?

Did you know that private medical practitioners in hospitals might charge more than your Medical Aid may cover?

That creates a shortfall, and it’s where Gap Cover comes in.

What is Medical Gap Cover?

There is often a gap between what your health practitioner charges for in hospital expenses and the amount your Medical Aid has agreed to pay. That’s when Medical Aid Gap Cover is used. Most medical aids also have defined co-payments that you have to pay on certain in hospital procedures. Depending on the gap cover you choose, these shortfalls could also be covered.

It’s a short-term insurance that makes up the shortfall between your healthcare costs in hospital and your current Medical Aid policy. It protects you from unexpected, exorbitant medical bills.

What’s the difference between Medical Aid and Gap Cover?

It’s important to note that Medical Gap Cover is not Medical Aid or an alternative to a Medical Aid. It is an insurance policy designed to complement your current Medical Aid.

If you don’t have Medical Aid yet, your first step is to compare quotes for a medical scheme that suits you and your family’s needs. Once that is in place, you’ll know what kind of Gap Cover you need.

How does Medical Aid Gap Cover Work?

So why is there a shortfall and how is it settled with Gap Cover? Medical Aid rates and healthcare rates are not the same thing. Medical Aid rates are fixed tariffs and some healthcare providers may charge more than that.

For example, you may have cover for up to 100% of the Medical Aid rate, but be charged 300% for hospitalisation expenses. In this instance, 200% of your expenses would be left unpaid. This is where Medical Aid Gap Cover is vital, as some policies will offer up to 500% above your Medical Aid. Most Gap products also cover defined co-payments imposed by your medical aid for certain in-hospital procedures without Gap cover, which would be your responsibility.

Why is Gap Cover Important?

Gap Cover is an important consideration in South Africa, where private healthcare rates and medical inflation often increase faster than other household expenses, and could become unaffordable.

Don’t put yourself at risk of needing financial assistance should your Medical Aid not cover all your healthcare costs in hospital. Rather protect yourself by comparing Gap Cover quotes in minutes!

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Medical Gap Cover FAQs

What is Gap Cover?

Everyone goes to hospital sometime in their life, sometimes for simple things, sometimes not. Costs (excluding the hospital bill) for certain procedures can run into thousands of rand's, which, if you are not fully covered, might cause financial ruin. With Medical Gap Cover, you will not need to worry about paying the extra cost for a hospital procedure you may have to undergo. There is a good possibility that you have to pay the specialist from your own pocket for a hospital procedure. Medical gap cover covers costs such as these.

Why Gap Cover?

In most cases, members have a shortfall between what the medical scheme pays and the actual cost, because the Service Providers are entitled to charge more than the tariff rate. The shortfall then becomes the member's responsibility and he/she will therefore need to have additional cover in these circumstances. Some Hospital and Comprehensive Medical Plans offer cover at 100%, 150% or 200% of the medical practitioner tariff rates, while the actual costs could be more than 400% of tariff rates. Gap Cover will cover the difference between what your medical scheme is willing to pay and the actual cost of in-hospital doctor's bills up to a maximum of 500% of tariff.

Who can apply for Gap Cover?

Gap Cover is available to individuals currently on a medical scheme.

Does it matter how large my family is?

No. However, certain products do limit the size of the family, or require certain criteria e.g. that all insured members must belong to a Medical Aid in order to qualify for gap cover.

What is the cancellation period?

Cancellation varies from a 30 day to 60 day cancellation period before any debits are stopped on your account.

Waiting period

The waiting periods clauses varies depending on the insurer. Pre-existing conditions are excluded for 12 months after the commencement date of the policy.

Benefit limits

The annual limits varies depending on the insurer.

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Covers the difference (shortfall) between what your Medical Aid pays and what a specialist charges. Gap Cover is not a substitute for Medical Aid.

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*Based on independent research by Kaufman Levin & Associates 2025.

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