This is Part One of our 2025 Gap Cover Guide.
Things to know upfront about Gap Cover:
- Gap cover works hand in hand with your medical aid plan to pay the portion of (in-hospital) bills that your scheme does not cover.
- A gap cover is not a stand alone product, and you need to be a member of a medical aid to make use of it.
- Gap cover is not sold by medical aid schemes. It is sold by short-term insurers. (Note that some schemes like Discovery Health and Momentum Health also have short-term insurers in their corporate structure)
- There is an annual limit of the maximum amount a gap cover can pay out per year. It increases every April, and in 2025 the limit is R210,580 per person per year.
- There are also sublimits for certain procedures, which are set by the insurer.
What’s paid by the Gap Cover?
Gap cover pays for shortfalls for in-hospital procedures and treatments. Sometimes a procedure is performed outside of a hospital, or does not require a hospital stay, but is still honoured by gap cover. Good examples of this are MRI scans, home births, and hernia repairs. Not all gap covers will pay these out-of-hospital claims, but many do.
Almost without exception, gap cover does not pay for every-day out of hospital consults like visits to your GP, dentist appointments or medicine. (Exceptions: Netcare Plus, Stratum for some benefits)
Waiting Periods:
When you first join a gap policy, you will likely have a 3 month general waiting period during which no claims will be paid. If you transfer gap covers, this may be waived.
Some gap covers will pay claims arising from accidents during those 3 months (Example: Ambledown), and some don’t have a waiting period at all (Example: Zest)
Pre-existing Conditions and Gap Covers:
There is usually a 12 month waiting period for pre-existing conditions.
If you are moving from one gap policy to another, these waiting periods can also often be waived or reduced. Waiting periods are usually “carried over” from one gap cover to another. You don’t have to start from scratch.
Age Limits and Gap Covers:
Gap covers can exclude members over a certain age (usually 65 or 75). The age limit usually applies to age at the start of the policy…the policy does not get cancelled once you reach the threshold age.
Some insurers have different (higher) rates for older members.
Family Membership for Gap Covers
Policies are usually quoted as “Individual” if there is only one person on the medical aid, or as “Family” if there are any dependants. You do not pay per person.
Children are only covered on the family plan up to a certain age – usually 21yrs. Once your child reaches the “adult” age, they will need their own gap cover.
Family members can belong to different medical aids but still have one gap cover policy.
What next?
In Part Two we discuss the Standard Benefits of a gap cover. Read that here.
