Gap insurance provides additional protection against unexpected medical expenses that exceed the limits of your standard medical plan. Despite being members of medical schemes, patients frequently find themselves in financial difficulties as a result of medical bills. This frequently results in financial stress and unplanned debt. When faced with such an expense, however, a Gap cover can protect you. Furthermore, it is available for use in in-hospital procedures by members of medical schemes. So, let’s get into what this insurance product is and how it can benefit you.

Understanding Gap Cover Insurance

Gap Cover Insurance South Africa

Gap cover is an insurance product offering short-term aid to patients who need extra protection in addition to their normal medical insurance. It is by nature a complementary product of medical scheme insurance cover and not a medical cover by itself. This is because it takes care of the difference between the amount charged by your medical care provider and the amount paid by your medical scheme tariff (MST).  

The South African Medical Aid Scheme presently compensates specialists and doctors at 300%, 200%, and 100% of the medical scheme rate. However, these professionals can charge close to five times the base rate. This increases the medical liability of a patient significantly and can cause financial strain in the course of treatment. Therefore, getting a Gap cover protects you and your dependents against this financial burden.

Benefits of Gap Cover Insurance

Gap cover is an insurance product offered by multiple insurance companies. Each of these companies has gap cover subclasses for different client needs. For instance, some Gap Cover products offer in-patient cover and specified out-patient benefits. In addition, some offer co-payment cover for medical scans, specific surgical procedures, and hospital admissions. However, some of the common benefits of Gap cover in South Africa include:

  • Supplementary illness benefits – this is where an insurer offers home support, lump sum payouts, and premium protection.
  • It takes care of the shortfall that arises between the doctor’s charges and what your medical aid scheme pays.
  • It covers upfront co-payments where you are required to pay for specific medical procedures or admissions beforehand.
  • Offers sub-limit cover in medical situations where your medical aid pays a portion of a number of specific medical situations from an annual limit or a sub-limit. These medical events include Renal Dialysis, Internal Prosthetics, Colonoscopies or Gastroscopies, and MRI and CT Scans.
  • It provides oncology cover to patients who have reached their yearly cancer treatment limit and have to pay for a part or the full amount charged for your treatment.
  • Some gap covers also avail lump sum cash to cater for the medical cost associated with the treatment of internal prostheses, certain cancers, treatment and care in a casualty ward, and accidental dentistry.


Unfortunately, not all South Africans qualify for Gap cover because of the eligibility criteria for this product target specific policyholders. Essentially, this product is available to anyone who is a member of a registered South African medical aid scheme and is below 60 years (in some cases, it is available to people over 60 years).

The cover extends to your wife or spouse and dependents like children of a certain age. However, your beneficiaries should also belong to the same medical scheme as you and have a similar medical option or plan to you.

Exclusions and Waiting period

Do exclusions and waiting periods also apply to Gap cover? Well, there are exclusions and a waiting period attached to the Gap cover. Generally, a waiting period of three months applies for all benefits and twelve months for all pre-existing conditions. In this period, you and your beneficiaries will not enjoy the cover.

Like any other insurance cover, the Gap cover also has exclusions. In simple terms, exclusions are treatments and medical procedures that are not covered by the Gap insurance product. Essentially, you will not enjoy the benefits of the cover should you suffer from any of the conditions excluded from the cover. Some of the common exclusions include specialized dentistry, cosmetic surgery, and obesity treatment.

Other than these exclusions and waiting periods, there are insurance providers who might decline to pay for the cost of co-payments that are defined as percentages instead of cash amounts in Rands. The insurer can also decline to cover your claims when:

  • Claims are more than six months old
  • You were slapped with any limit, co-payment, and penalty by your medical aid scheme due to non-compliance with authorization procedures or scheme rules

How to Choose Gap Cover Provider

Choosing the best Gap cover provider for your needs will ensure all your needs are taken care of conclusively. Therefore, when choosing the right Gap cover provider, there are qualities that you need to look for to ensure the company can serve you well. Find a company that is financially stable, has a good review among clients, and has a significant customer base. In most cases, people gravitate to companies with top-notch services. 

You should also seek to know about the company’s quality of service before committing to becoming a member. Here are some of the questions you should seek to answer when finding a Gap cover provider to get services from:

  • Does the company provide cover for medical procedures carried out of the hospital?
  • What’s the company’s maximum benefit age and entry?
  • Does the company provide first-time cancer benefits to its members?
  • What’s the company’s general Gap cover limit?
  • Are there waiting periods, and what are they?
  • What are the exclusions?

Where to Get Gap Cover in South Africa

There are different Gap cover providers in South Africa. It is essential for you to choose one with the right qualities for your specific needs. Here is a list of companies that can offer you a great deal when choosing Gap Cover.

According to a publication by news24, Sanlam and Absa offered some of the amazing Gap cover products. This is justified by the value offered by the two companies. For instance, according to the publication, Sanlam offered value for money to members under 60 years since you have to pay about R250 every month per family or individual for the company’s comprehensive Gap cover. Absa, on the other hand, offers the best value for money to families or individuals over 60 years. They do this through their R435 per month Gold plan cover. In both plans, users enjoy a comprehensive Gap cover with co-payment, sub-limit in the 500% sector, and oncology. Here are other Gap cover providers that you should consider.

Gap Cover Medical Shortfall Solutions

Here, members can access two types of products, namely Gap cover elite and Combined cover. Each of these product packs features is suited for different classes of clients. If you opt for Gap cover elite, you will have to pay R295 per family and R192 per individual every month. Some of the benefits that you will enjoy under the Gapelite cover include:

  • Non-DSP Specialist tariff shortfalls for planned PMB admissions
  • Oncology benefit
  • Hospital Cash Back Benefit from day 3
  • Cash Back Benefit
  • Sub-limit benefit – internal prosthesis and specialized radiology

If you opt for the combined cover, you will have to pay R299 per family every month. This cover offers both in-hospital and out-hospital benefits to its members. The in-hospital benefits include:

  • Tariff shortfall – this benefit caters to the difference in charges between the amount paid by your scheme and that demanded by a medical professional while being treated in a hospital.
  • Deductibles and co-payments – this caters to procedural co-payments 
  • Dental – these benefits cover the dental shortfall on procedures 

The out-of-hospital benefits include:

  • Tariff shortfalls – this caters to a shortfall in colonoscopies and gastroscopies performed in specialist rooms. It is limited to two scopes for every beneficiary per year
  • Deductibles and co-payments – the benefits in this class caters to procedural co-payments for all the procedures carried out as an out-patient and specialized radiology
  • Emergency ward benefits – cover the shortfall incurred when treating injuries resulting from external forces at an emergency ward. It is limited to two events amounting to a total benefit of R5950 per policy per year
  • Physiotherapy – this benefit caters to the cost of out-of-hospital physiotherapy not exceeding R1800 per policy, per year

Other Gap Cover Providers

There are many other Gap providers in South Africa offering a wide variety of products for your short-term medical shortfall needs. They include:

  • Stratum Benefits – Stratum Benefits offers a wide range of products, including Compact 200, Elite, Base, and Co-Evolution. These options are readily available to any South African on a recognized and registered SA medical aid. However, members of Bonita’s Boncap, Discovery Essential Smart plan, Discovery KeyCare, or Momentum Ingwe can access the Gap cover through the Access Optimiser Plus option.
  • Discovery – Discovery offers covers for businesses and individuals.
  • Momentum – you can get the momentum Gap cover from R203 per month

Being a member of medical aid is important. However, It might not be enough to cushion you from medical bills. It is, therefore, wise for you to get a Gap Cover for medical shortfalls. You can be able to wrap your head around this topic and find yourself a good Gap cover with the help of this piece.

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