This is Part Two of our 2025 Gap Cover Guide.
Gap Covers’ Standard Benefits
Gap Covers exist to bridge the gap between what doctors charge and what medical aid pays, mostly for in-hospital treatment and procedures.
There are many Gap Cover products, with different combinations of benefits and rules. However, all Gap Covers will have some combination of Standard Benefits, which allows you to pick and choose the product that has exactly what you need to match your medical aid plan.
- Shortfall benefit for specialists. This is for when your specialist charges more than your medical aid is willing to pay
- Co-payment benefit. Pays the co-payment required by your medical aid eg. for MRI scans or dental admission.
- Sublimit benefit. Extends sublimits set by your medical aid for various benefit eg. for prosthetic devices
- Network penalty benefit. Pays the penalty for admission to a non-network hospital
- Oncology benefit. Extends the oncology (cancer) benefit provided by your medial aid.
- ER benefit. Pays for emergency visits, if not covered by your medical aid.
Tip: for most medical aid shortfalls due to out-patient services like consults, dentistry and GP visits, you need a primary care insurance product, not a gap cover.
Scheme-rate shortfalls
Most medical aid plans pay doctors at 100% scheme rate. But unless the doctors have a contract with the scheme, they are free to charge whatever they want. In fact, many doctors charge anything from 2x to 7x the scheme rate, and expect you to pay the difference out of pocket.
A gap product can cover that difference, up to a pre-determined limit. Most gap covers will pay at least 2x scheme rate, and some go as high as paying the full 7x.
Tip: If your medical plan has strict restrictions on what hospitals you can use, and it guarantees full payment of doctor’s account, you might not need this benefit. You can choose a cheaper gap cover that does not offer it (Example: Ambledown Guardian).
Co-payments and sublimits
Almost every medical aid plan has some combination of co-payments and sublimits for some procedures. You can avoid these extra costs with a gap cover benefit that pays the co-payments, or increases the sublimits.
Tip: Co-payment and Sublimits are usually two separate benefits on a gap cover. Only choose both if you actually need both!
Non-network penalties
If you are on a Network medical aid plan, you often have the option of using a hospital outside your network, but you need to pay a penalty. For example, Discovery Health Delta Saver plans charges R10,200 penalty and Momentum Custom Associate plans charge 30% of the hospital account as a penalty if you use a hospital outside the network.
Some gaps cover one or two of these penalties per year, either in full or in part. This benefit can be per person or per policy.
Note that these network penalties are different from the penalties imposed for not following protocol eg. not authorising a procedure before admission. Those type of protocol penalties are never paid for by a gap cover.
Tip: Netcare Plus gap cover pays unlimited penalties for admission to Netcare hospitals.
Emergencies
Emergency ER visits are rarely negotiable, yet always expensive. And although medical aid will pay for these if they result in a hospital admission or end up being a PMB, sometimes ER visits are serious but not that serious. For those situations, there are gap covers that will cover the bills, including consults, x-rays and treatment.
There are 3 common types of gap cover ER benefits:
- Accident only: this covers accidental injury only eg. fractured leg or a deep flesh wound
- Illness: this covers non-accident cases, eg. pain to chest, asthma attack, persistent vomiting
- Cover for Children only: this usually covers children’s visits to the ER outside of usual GP hours ie. in the evenings and over weekends, for accidents and/or illness. Usually limited by age. (Example: Kaelo)
ER benefits usually have a sublimit (around R8,000-R20,000).
Tip: When choosing a cover, check whether this benefit is per person or per family, as this makes a huge difference!
Cancer/ Oncology
Medical schemes have to pay the full cost of any PMB condition, and most cancers are PMBs.
However, when you get more comprehensive treatment than the PMB level of care, most medical schemes impose a limit, and/or might require a co-payment. For example, Discovery Health Comprehensive plans require a 20% co-payment for non-PMB care, when you reach the R400,000 oncology limit and Medihelp MedAdd has a R275,100 sublimit for non-PMB oncology.
In addition, there might be specific sublimits or exclusions (eg. Bonitas limits brachytherapy on most plans). You might also have a co-payment if you don’t use the required service provider.
A gap cover might help with any of those scenarios:
- Can pay the co-payments or increase the sublimit.
- Some gap products cover innovative oncology medicines (usually your medical aid needs to offer this benefit too) (Example: Kaelo, Ambledown)
- “Payout on first diagnosis”. Some gap covers will pay out a once-off lump sum on the first diagnosis of cancer. Usually limited by age, and some cancers are excluded. (Example: Ambledown, Stratum)
Tip: If you have a cancer diagnosis prior to signing up with a gap cover, you will most likely have a 12 month waiting period. But the sooner you start, the sooner the waiting period will be over!
Premium Waivers
If you die or are disabled, some gap insurers will pay a lump sum, and/or pay your family’s medical aid and gap cover premiums for 6 months.
These benefits are not subject to, and do do not count towards the usual R210,580 annual payout limit.
Dental Procedures
The way dental procedures are dealt with by medical schemes is complicated! They have different rules for wisdom tooth extractions, specialized dentistry (eg. implants), reconstruction surgery (trauma or illness), and admissions for young children. Many dental admissions that are not PMBs require co-payments, and have strict sublimits.
But be careful. Gap insurers also have many rules for dental procedures, so make sure that the gap cover you choose plays nice with your medical aid plan.
Some procedures might be fully excluded by a gap cover (common with specialized dentistry), but included for reconstruction dental surgery due to accident or illness, or for child admissions.
What next?
In Part Three we discuss the Bonus Benefits of a gap cover. Read that here.
