GAP COVER – an essential portion of your health care cover

As you  probably experienced already,  most of the time after you’ve been in hospital or had a medical procedure done, there is usually an amount that the Medical Scheme doesn’t cover and which you have to pay in, that is what we call the shortfall OR GAP!  Read further to understand why having Gap Cover is a good decision.

Even though the medical scheme covers your in-hospital procedures, you are still exposed to the risk of large out of pocket payments for in-hospital procedures.

Specialists charge 300 – 500% more than what your medical scheme pay for in-hospital procedures.   These shortfalls can vary from a few thousand rand to tens of thousands of rand. It can be R10 000 or R50 000 or even more.

Listed below are four common medical procedures, with the combined charges of the specialist and anaesthetist.  In the third column the shortfalls not covered by the medical scheme are listed.


Procedure Amount charged by Practitioner Potential shortfall incured (Payable by Gap Cover*)
Colonoscopy R 14 509.82 R 4 805.42
Back Fusion R81 499.11 R27 949.89
Shoulder Operation R19 081.86 R11 958.34
Joint Replacement R46 660.48 R23 597.41


Gap Cover insurance is an affordable way to protect yourself against this once off high risk.  It is easier to make provision for a small monthly payment of R250 – R450 per month in your monthly budget than to be confronted with the shock of having to pay R50 000 at once.

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Can I use any Gap Cover product in conjunction with any medical aid?

Yes, you can use any Gap Cover product whilst a member of any of the registered medical schemes in South Africa.

Are maximum annual limits applied to Gap Cover products?

Yes, the same maximum annual limit applies to all Gap Cover products.

The maximum benefit payable per policy is R165 000 per person registered on the policy per year.

How do I claim from Gap Cover?

The following documentation should accompany your completed Gap Cover claim form:

  1. Detailed copies of all relevant doctors’ accounts.
  2. Clear copy of the Hospital account (Contact the Hospital for a copy).
  3. Detailed Medical Scheme statement, reflecting the shortfall (Contact your medical scheme for a copy).
  4. Authorization confirmation (Contact your medical scheme for a copy).
Why do Gap Cover products apply waiting periods and 12 month exclusion on existing conditions?

The Gap Cover product cannot apply risk underwriting to the premiums, in other words charge a higher monthly premium for individuals with a higher health risk profile.  The only protection a Gap Cover product has  to prevent people from joining, have a major operation in the first month, claiming R50 000 and then resign again, is the 3 month general waiting period.  The same principle applies to the 12 month exclusion on pre-existing conditions.

Gap Cover premiums are very low in comparison to medical scheme premiums.  The shortfalls on an in-hospital procedure with regards to the anaesthetist and surgeon accounts can be as high as R50 000 to R90 000.

Why doesn’t the Gap Cover product pay medical service providers directly?

Firstly, it is important to understand that Gap Cover is a short term product and therefore has to apply to regulations in the Short Term Insurance Act.

As per legislation the Medical Schemes Act does not apply to Gap Cover  – which is the reason why a Gap Cover product is by law prevented and restricted from fulfilling the function of a medical scheme:

  • Gap Cover is not allowed to pay medical expenses and procedures not covered/paid by a medical scheme
  • Gap Cover is not allowed to pay medical service providers directly, pay into member’s bank account
  • Gap Cover is not allowed to pay for any procedures that is not paid by the medical scheme

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