A good gap cover is an essential addition to any medical aid plan.

It will save you money: both in actual medical expenses as well as possible lower medical aid premiums.

We have designed these gap covers as a combination of excellent benefits and superb prices.

Side by side comparison

Plan Red: Plan Blue:
Total Cost per family (everyone under 65yrs): R99pm R299pm
Total Cost per family (anyone 65yrs+): R150pm R435pm
1. Shortfall benefit: No
This gap is perfect for network plans that guarantee full payment to specialists
2. Co-payment benefit: Yes Yes
3. Sub-limit benefit: Yes Yes
4. Cancer benefit: Yes Yes
5. ER benefit: Yes Yes
6. Dread and Premium Waiver benefit: No Yes

Quick explanation of benefits

    1. Shortfall Benefit
  • Covers any shortfall between what your medical aid pays your doctors and what they charge, for in-hospital services
  • Tops up payment up to five times (total) of what your medical aid plan is prepared to pay (up to 500% scheme rate, including the payment from medical aid)
  • Only pays for in-hospital services
  • The small print: does not pay extra for accommodation, appliances, food, wards, materials such as bandages or blood.
  • More detailed information here
    2. Co-payment benefit
  • Covers co-payments that your medical aid requires you to pay for any in-hospital procedures
  • The gap also pays any co-payments for out of hospital MRI and CT scans
  • The small print: does not pay for penalties, or for co-payments that you incur for not using a network/DSP doctor or hospital, if required to by the medical aid. Does not pay penalties for using out-of-network hospital.
  • More detailed information here
    3. Sub-limit benefit
  • If your procedure costs more than the sub-limit imposed by your medical aid, the gap will cover the difference
  • The gap also increases sublimits for out of hospital MRI and CT scans
  • More detailed information here
    4. Cancer benefit
  • The gap will cover any co-payments required, or pay all costs over and above sub-limits imposed by your medical aid
  • This includes all treatment, chemo, radiation and biological medicines if that is a benefit offered by your medical plan
  • The small print: you or your scheme need to have paid the first R200,000 for cancer treatment per treatment cycle at a private facility, before this benefit kicks in. Out of hospital specialist visits are not covered by this benefit.
  • More detailed information here
    5. ER benefit
  • The gap will cover costs incurred as a result of an emergency, treated in the ER, and not paid by your medical aid, up to R20,000 per person
  • You are covered when immediate treatment is required
  • This benefit will cover the facility fee, consultations, medications, radiology and pathology associated with admission to a registered hospital’s casualty facility.
  • The small print: “Emergency” means the sudden and at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or death. The determination of an Emergency will be done through diagnosis (through classification by the attending Medical Practitioner and / or the Casualty Unit) and not on symptoms presented. The Medical Practitioner that treated you and / or the Casualty Unit that you have been treated in should use the correct codes and classification on the invoices they send to you and /or your medical aid.
  • More detailed information here
    6a. Dread Disease benefit:
  • Provides a once off dread disease benefit (R50,000), limited to first diagnosis of cancer.
  • The small print: The benefit will be excluded for any current member who has been diagnosed prior to inception and is payable once in a lifetime per insured person. Benefit terminates when person turns 65. There are a number of exclusions.
    6b. Premium Waiver benefit:
  • This benefit covers the actual medical scheme contributions following the death or the total and permanent disability of the principal member of the Medical Scheme, for 6 months
  • The small print: Benefit terminates when person turns 65
    What other small print is there?
  • All benefits numbered 1 – 5 above can be paid up to a combined maximum of R150,000 per person per year
  • Gap benefits apply to procedures/treatments approved by medical aid. No approval = no gap cover benefit
  • Always read your full policy document in full to be aware of the conditions and limitations of cover

Other articles about AskAdam gap cover

For more information on the gap product, please read the articles below, or contact us with any questions.

The AskAdam gap products are not a medical scheme, and the cover is not the same as that of a medical scheme. The policy is not a substitute for medical scheme membership. The master policy issued is the source of all benefits, and obligations and exclusions.

Please join our newsletter!

We tell you things your medical aid does not want you to know. Fun, huh?