Paying R5000 or more a month for medical aid should mean you’re covered for almost anything. But the reality is, even top-tier medical aid plans in South Africa don’t cover the total medical bill.
Thousands of South Africans pay R5,000 or more every month for medical aid.
Many feel that a premium medical aid scheme covers it all, but specialists are more commonly charging above medical aid tariff rates, making shortfalls almost inevitable, regardless of your medical aid plan.
That’s why you need Gap Cover.
Healthcare Costs in South Africa
Healthcare costs in South Africa are rising, and the gap between what medical aid pays and what you actually owe is only getting wider.
Medical aid premiums in South Africa are rising at rates far above salary increases and inflation. According to BusinessTech, in 2024 for 2025, major schemes announced hikes well above the Council for Medical Schemes (CMS) recommended range of 6.4% to 7.9%. However, the average increase was around 10% across multiple providers. In contrast, average salary increases were expected to be around 6%, meaning most South Africans saw their medical aid costs outpace their earnings.
Soon, the 2026 figures will be announced, and it is expected that most medical schemes will increase premiums by 6.55% to 9.9%, with some even entering double-digit territory.
Why are premiums rising so much?
Medical inflation has consistently exceeded the Consumer Price Index (CPI) by 2% to 3% annually, and for 2026, it is expected to reach approximately 10%. During the COVID-19 pandemic, schemes built up reserves and kept increases below CPI, but as claims have returned to pre-pandemic levels, schemes must now adjust premiums to match rising healthcare costs and maintain sustainability. This has led to higher-than-recommended increases, with some schemes tightening benefits and adding more restrictions to contain costs.
The individuals and families that plan ahead and invest in supplementary healthcare cover will be better prepared for even more unexpected medical expense shortfalls.
The Illusion That Medical Aid Is Enough
The common assumption is that medical aid covers all of your healthcare-related costs, and the higher your medical aid premium, the more cover you receive. Although this is somewhat true, specialists still charge above medical aid rates, leaving you with medical expense shortfalls, co-payments, and medical bills you didn’t expect.
Gap cover bridges this gap between what your medical aid pays and the full cost of treatment, so you’re not left with surprise medical shortfalls.
“I Can Afford The Difference”, But Why Should You Need To?
Many people on more comprehensive plans think, “The shortfall can’t be that much. I can afford it.”
Maybe you can, but why should you?
Shortfalls can lie anywhere, even between R5000 and R100 000 (or more), and as long as it falls within the annual aggregate limit* and policy limits, your gap cover policy could cover it.
The annual aggregate limit in 2025 is R219 845 per insured person
Even if this is something you can pay out of pocket, why pay out unnecessarily?
Gap cover plans are tiered, designed to meet you where you are and what you can afford.
| Plan | Premiums 2025 | Premiums 2026 | Above Tariff Coverage |
| Basic Cover 300 | R99 for individuals R180 for families R360 for over 65s | R99 for individuals R197 for families R394 for over 65s | 300% |
| Vital Cover Plus | R360 for individuals and families R540 for over 65s | R394 for individuals and families R591 for over 65s | 700% |
| Super Cover Plus | R380 for individuals and families R570 for over 65s | R417 for individuals and families R626 for over 65s | 700% |
| Absolute Cover Plus | R620 for individuals and families R770 for over 65s | R681 for individuals and families R846 for over 65s | 700% |
Read more about what is included in each policy.
Medical Aid Shortfalls in Action
When you go in for a hospital procedure, you expect your medical aid to cover everything. Instead, you receive a bill for the difference between what your scheme pays and the providers’ etc. charge.
Without gap cover, you could be paying thousands out of pocket.
If you’re already investing in a comprehensive medical aid plan, Gap cover is a relatively small financial commitment that ensures you’re covered when your medical aid pays less than the full cost.
Here’s a recent case study for a Pregnancy shortfall in 2025:
| Total Medical Bill | Monthly Medical Aid Premiums (2x Adults) | Amount Paid by Medical Aid | Shortfall Amount Covered by Gap Cover | Gap Cover Premium (TRA’s Absolute Plus) | Amount Owed by Patient |
| R90,562.55 | R6 652p/m | R51,514.23 | R38,309.30 | R620p/m | R0 |
Growing your family shouldn’t leave you worrying about a hefty R40,000 hospital bill on top of everything else.
Why You Need Gap Cover
According to the Council for Medical Schemes, in 2023/2024, South Africans paid over R40 billion out of pocket in co-payments and shortfalls alone. Don’t let yourself fall into this statistic if you can help it.
What Gap Cover Actually Does
Gap cover is designed to fill the “payment gaps” left by your medical aid. It typically covers things like:
- Medical expense shortfalls
- Co-payments and deductibles
- Specialist treatments and procedures
- Oncology treatment
- In-hospital dental reconstruction
- Accidental Death cover
- Waiting periods and annual limits that make sense
Whether it’s a hospital procedure, specialist treatment, or unexpected medical expenses, gap cover can ensure that you’re fully covered, no matter what your medical aid pays.
TRA Gap Cover Benefits
Total Risk Administrators (TRA) is an authorised financial services provider – FSP No 40815. We are underwritten by Auto&General Insurance Company Limited, a licensed non-life Insurer and Financial Services Provider. We have a reputation for supporting South Africans who live larger than life and want peace of mind.
With TRA, you get:
- Comprehensive coverage for medical aid shortfalls, co-payments, sub-limits, specialist treatments, and procedures
- Competitive above tariff coverage – very few providers offer up to 700%
- Benefits that adapt to your family structure and lifestyle
- Support for medical scheme membership changes
- Fast payments and clear policy terms
- Additional benefits for oncology, dental reconstruction, and more
- Overall annual limit and maximum amount of protection
- Travel insurance and additional benefits through TRA Assist
Find out more, or download our 2025 Gap Cover Brochure
Don’t Wait Till It’s Too Late, Choose TRA
If you’re paying R5,000 or more a month, you deserve to be fully covered.
Gap cover will give you confidence in your medical coverage again. Review your coverage and speak to your intermediary today.
Get TRA Gap Cover Today
Don’t wait for the next big bill to find out what your medical aid doesn’t cover.
