Everything You Need To Know About Gap Cover for Medical Aid

Many South Africans find themselves in a predicament once they discover that their medical aid schemes will not cover the entire amount of their hospital bills. At this stage Gap Cover for Medical Aid comes into play.

Individuals find themselves in debt when faced with the reality of finding a way to pay the remainder of the medical bills which can be close to 500% of the medical aid scheme rate.

What many individuals don’t know is that one can get cover for medical aid that will “close the gap” when those trying times arise, and it’s called Gap Cover.

Gap Cover is a short-term insurance product which provides cover for individuals whose medical aid scheme does not cover the full amount charged by hospital bills due to: hospitalisation, in-hospital treatment, operations and day clinic.

It is quite affordable, and the insurer pays out to the principal member of the policy.

Gap cover is highly recommended for medical aid scheme members, as it protects them from the unforeseen.

*Please note that Gap cover is not a substitute for medical aid but merely a top-up for any costs incurred by shortfalls suffered after payments.

How gap cover for medical aid works

One thing to note is that Gap Cover is very affordable. The plan can cover the principal member and their dependents that are members of a medical aid scheme.

The member can make one lump sum or commit to a monthly payment and rest assured that the Gap Cover will cover them should their hospital bills need to be paid.

Gap cover for medical aid has a few types of plans available. Designed to cover the amount the medical aid scheme is not able to cover, there may still be a small amount that the member will be responsible for paying out of his/her pocket. Refer to the example below:

If the procedure cost R10 000 and the medical aid can only pay R4 000, that means that the Gap Cover is expected to pay the remaining R6 000. But if your gap cover for medical aid plan can cover R5 000, that means the remaining R1 000 will have to come out of the individuals pocket.

Hence it is of vital importance that before you take out Gap Cover for Medical Aid, you read the fine print satisfactorily, and ensure that you choose Gap Cover that can either pay double, triple or four times what your medical aid scheme will pay out.

So whichever amount your medical aid scheme can afford in any situation, rest assured that Gap Cover for Medical Aid will pay according to the cover (double or triple), and if there is still a shortfall after that, the onus lays on the owner.


Various services providers offers additional benefits that are suited for the individual and his/her family and covers any shortfalls, such as:

Casualty Benefit

This benefit pays out to you in the event of emergency hospitalisation. In the case where you have to pay from your pocket or if your medical aid takes out funds from your acute account, the causality benefit will pay off the money owed to you.

Gap Cover Premium Waiver Benefit

A waiver benefit in which the insured party will not be required to pay any extra costs in the event of death or disability that may prevent the cover from paying. So the Gap cover premium waiver benefit protects the member from paying additional fees to keep the policy running.

Oncology Benefits

The Gap cover pays for costs that the medical aid schemes in South Africa do not cover for the treatment of cancer. The only payment that the member might be liable for will be the co-payment which is the payment required by the medical aid for the admin costs.

Trauma Counselling

This benefit pays out for members who have affected by:

  • Dread disease
  • Have witnessed a traumatising event

Sub-limit Benefit

This benefit pays out for limits that have been applied by medical aids to the amount of money given for internal prostheses. So the Gap Cover pays for the costs the medical aid cannot cover.

Accidental Death Benefit

This benefit provides payment for accidental death experienced by the primary member, spouse or benefits. Different plans pay out different amounts.

Rehabilitation Optimiser Benefit

The benefit covers therapy and physiotherapy for any unforeseen events. Some medical aid options provide a limit to the number of sessions a member and his/her beneficiaries can have. Gap cover for medical aid covers the gap between what the medical aid scheme is willing to pay and what your therapists charges.

Preventative Care Benefit

The Preventative Care Benefit covers any excessive amounts charged for pre-screening tests such as pap smears and prostate cancer screenings.

Top-up Cover

Some covers are inclusive of all the benefits and allow the member to choose which cover they require at that specified time.

This covers will also a payout for unique cases such as bunion surgery and Cochlear implant.

Some options do cover for conditions that medical aid schemes might not cover, such as nasal procedures.

It is imperative to choose a medical aid plan that will cover the benefits needed so that the Gap cover will also be able to match the cover.

Gap cover for medical aid will not pay for anything that your current medical aid scheme does not cover.

It is also essential to examine the fine print in all covers and also, to observe the percentages of medical aid rates the gap cover does cover.

Gap cover for medical aid will pay for the following:

  • Hospital and consultation procedures
  • Co-payments for certain hospital procedures (in full)
  • Payment for cancer treatments once medical aid scheme can no longer pay for it
  • Payment (up to a certain amount) for any shortfalls suffered on prostheses surgeries
  • A lump sum for first-time cancer diagnosis (terms and conditions usually apply)
  • Lump sum payment for accidental death or permanent disability
  • Lump sum for long-term hospitalisation over a stipulated period
  • Dentist benefits that can contribute to repairs such as breaking a tooth in a car accident)
  • Some casualty costs

* The above may differ from one service provider to another

Gap cover for medical aid will not pay for the following:

  • Wardroom payments;
  • Private room upgrades;
  • Consultation costs that occur before admissions;
  • In hospital and day to day Medication
  • External prostheses (an artificial breast or a prosthetic leg);
  • Wheelchairs or crutches (also referred to as external appliances);
  • Routine medical examinations, such as ultrasounds;
  • Home or private nursing;
  • Extra costs related to weight/BMI-related procedures;
  • Mental health disorders, transportation costs (such as in an ambulance);
  • Out-of-hospital dental treatments;
  • Cosmetic procedures;
  • Costs incurred for treatment by a non-designated service provider (determined by your medical scheme); and
  • Co-payments for any procedure for which you are in a waiting period.

* The above may differ from one service provider to another

Waiting period

There is generally no waiting period for most plans. But with most, a waiting period is imposed on pre-existing conditions such as pregnancy.

Membership for gap cover for medical aid covers:

Most plans will cover individuals that are below the ages of 65, with some covers making allowance for individuals older than 65 (which may cost more). Individuals can also cover their spouses even if they are on different plans.


Keep in mind that gap cover for medical aid premiums will and can increase annually, as it is an insurance product.