The concept of “Gap Cover” is becoming more and more accepted as a vital part of your total medical aid package. Nowadays, most conversations about medical aid also includes reference to Gap Cover.


But what is Gap Cover and why is it important? When you are hospitalised, there is no guarantee that your medical aid scheme will cover the full cost of the treatment in hospital. You might be on a scheme that pays 100% of the tariff. So what’s the big deal – if you are on a 100% scheme, then the scheme should cover it all in full, right? Wrong! The problem is that many service providers could in fact charge 200% – 500% of the relevant scheme tariff.


Your surgeon and your anaesthetist are pretty much at liberty to charge whatever tariff they like. In our experience, we have seen some accounts from members where the surgeon charged 400% of the relevant scheme tariff. This left the member with a huge portion of the account to pay. Their scheme paid the 100% and the member was left with the shortfall of 300% to pay out of pocket. And this shortfall can run into several thousand rand, as shown in the table under – it is an actual example of what happened to one of our clients.


Description Specialist Amount charged by the service provider Paid by the medical scheme PORTION THAT THE MEMBER HAD TO PAY
Anaesthetist R3 770 R1 482 R2 288
Gynaecologist R8 833 R2 759 R6 074
Total R12 603 R4 241 R8 362


In this case, the member did not have a Gap Cover policy and had to pay the R8 362.36 out of their pocket! If they had Gap Cover, this R8 362 shortfall would have been refunded directly to them and they would not have been out of pocket. In this example, this R8 362 could have bought the family over 3 500 disposable Huggies nappies – that’s enough for 3 years!!!


The claims process is simple. We assist clients to submit their claim to the Gap Cover provider. It is unfortunately not a single process – once the medical scheme has processed the amount, then a second claim must be submitted to the Gap Cover provider.


Gap Cover pays a cash benefit directly and the member then has to pay the doctor’s directly. Gap Cover is not allowed to settle the service providers directly. Secondly, Gap Cover policy therefore exists side-by-side to your membership of your medical aid scheme – it is not a substitute for a medical aid scheme.


There is some discussion in government about these Gap Cover policies. However, no final decision has yet been made, so Gap Cover remains a valuable tool to protect yourself against the shortfalls that will arise when you are hospitalised.


The cover is affordable and valuable.  Need more information? Interested? Contact us on or call us at 021 465 0071 and we will assist you.