How do gap covers work?

Paying for shortfalls

If you have an in-hospital procedure, very often you will have to pay for services out of pocket, even if you have medical aid. This can be because:

  • Your doctors charge more than your medical aid has agreed to pay them
  • There is a co-payment you have to pay upfront
  • There is a sublimit, and you surpass it
  • You have used a non-network hospital, against your plan’s rules.


In some cases (note: not all!), your gap cover will pay the shortfall. Whether the shortfall will be paid depends on

  • the amount of the shortfall,
  • the procedure,
  • the reason for the shortfall and
  • which gap cover you have.

You should also know that:

  • Gap covers are not medical aids, and fall under short term insurance. They have a limit of R150,000 benefit per year per person, per policy, but you can enhance that up to R450,000 per person per year (by taking out additional cover).
  • Just like most medical aids, gap covers have specific waiting periods (usually 12 months for pre-existing condition that you have received advice or treatment for in the past 12 months) and a general waiting period (usually 3 months, but not applicable to accidents).
  • You need to be a member of a medical aid to enjoy gap cover benefits.
  • Premiums are usually paid per family, although some covers have premiums for single members. There is no limit to age for entry (from January 2018), but higher premiums usually apply if a member of the family is 65years or older.
  • Gap covers have “extra” benefits, such as disability cover, cash payouts for hospital stays, ER/casualty benefit etc. This is dependent on the cover.
  • Some medical aids have partnered with gap covers, but you are not obligated to take that specific cover. Some gap covers are only available to members of specific schemes.
  • Gap covers have exclusions. Please read your policy document carefully! Where we profile a gap cover, we will outline these for you.
  • Generally, gap covers do not pay for day-to-day claims, although some will pay for out of hospital MRIs, procedures done in doctor’s rooms etc.
  • Where a medical aid rejects or excludes your claim, the gap will not cover it either.