If you have shopped around for gap cover in South Africa, you have probably seen plans advertised at 200%, 500% or 700%. The numbers look arbitrary, and most brochures do not bother to explain them. They matter, though. The percentage on your gap cover policy is what decides whether your bill from the anaesthetist/other specialists, for in-hospital procedures, will be settled in full or leave you owing thousands.
This article walks through what those percentages actually refer to, how they play out on a real account, and what each of TRA’s four 2026 plans cover.
Start With The Scheme Tariff
Firstly, remember that gap cover is mostly for in-hospital procedures, not every time you go to a GP etc./ day to day benefits. There are some exceptions (but even then these benefits are often tied to procedural events), and where the percentage tariffs fall in is mostly for these procedural events. Click HERE for more summarised information regarding this.
Secondly, every medical aid in South Africa pays specialists and hospitals according to its own published rate. That rate is called the scheme tariff, sometimes the scheme rate or the medical aid rate. It is, in effect, your medical aid’s idea of what a given procedure should cost.
The problem is that specialists do not have to accept it. Many charge above scheme tariff, sometimes a little, sometimes a lot. Anaesthetists are a common example; certain surgeons, oncologists and sub-specialists are another. The difference between what your specialist charges and what your medical aid is prepared to pay is what the industry calls a tariff shortfall. The shortfall lands on you.
How The Percentages Fit In
When a specialist charges 300% of the scheme tariff, they are charging three times what the medical aid will pay. At 700%, they are charging seven times. That sounds extreme, but in some specialities, it is closer to the norm than the exception.
Gap cover is designed to cover that shortfall, but only up to whatever percentage is stated on your policy. So if your gap cover pays up to 300% and your surgeon’s account comes in at 700% of scheme tariff, your gap cover will pay the bit between what the medical aid covered and that 300% ceiling. Everything above 300% is your problem.
A Worked Example
Take a procedure where the scheme tariff is R10 000.
Your medical aid pays R10 000 (its 100%). Your specialist charges R70 000 (700% above scheme tariff). The shortfall is R60 000.
Now compare what different gap cover levels would do with that shortfall:
| Gap cover percentage | What gap cover pays | What you still owe |
| 200% gap cover | R20 000 | R40 000 |
| 300% gap cover | R30 000 | R30 000 |
| 500% gap cover | R50 000 | R10 000 |
| 700% gap cover | R60 000 (would pay R70 000 but the medical aid has already covered R10 000) | R0 |
So the gap between a 300% policy and a 700% policy for the same procedure is R30 000 in your pocket. That is why the percentage on the brochure deserves more attention than it usually gets.
To explain further, for example, a 200% gap cover policy means that the insurer can cover up to an additional 200% of the medical aid tariff, on top of what your medical aid already paid.
Where TRA’s Four Plans Sit
For 2026, TRA offers four gap cover plans. On the tariff shortfall benefit, three of them sit at 700% and one sits at 300%.
Basic Cover 300 is the entry-level plan. The tariff shortfall benefit pays up to 300% of scheme rate, which is enough for many GP-level procedures and the lower-charging specialists. Premiums start at R99 per month for an individual or R197 per month for a family. If price is the main consideration and your medical aid is on a plan with strong specialist arrangements, this is the cheapest way to start.
Vital Cover Plus takes the tariff shortfall benefit up to 700%, which is the level at which most specialist charges in South Africa are fully covered. It also adds a co-payment benefit for in-network procedures (up to R14 335 a year), basic internal prostheses cover, and an in-network oncology co-payment benefit. Premiums start at R394 per month for under 65s.
Super Cover Plus keeps the 700% tariff ceiling and broadens almost every other benefit. The in-network co-payment cover rises to R66 150 a year, out-of-network co-payments are included for the first time, there is an MRI/CT/PET scan co-payment, a step-down facility benefit of R8 000, an oncology extender benefit, the R15 000 premature birth benefit, and a maternity follow-up consultation benefit. Premiums start at R417 per month for under 65s.
Absolute Cover Plus is the top plan. It sits at 700% on tariff shortfalls and then makes most of the other benefits effectively unlimited, with the aggregate annual limit of R219 845 per insured person sitting over everything as the cap. Co-payments, out-of-network use, MRI scans, internal prostheses, oncology, and even private ward upgrades on hospital admissions get the fullest treatment available in the range. Premiums start at R681 per month for under 65s.
How To Choose Between The Percentages
The honest answer is that it depends on how often the people on your medical aid see specialists, and how much risk you are comfortable carrying yourself. (We have a separate guide on how to compare gap cover plans if you want a structured walk-through.)
If specialist consultations which could lead to surgeries are part of your normal year, a 700% policy is almost always going to pay off. Specialists are where tariff shortfalls bite hardest, because they have the most pricing freedom. The people who get caught out are the ones who chose a lower-tier policy on price and then needed a specialist for a routine operation.
Gap Cover (especially a 700% option) can be very beneficial for many procedures which may occur in one’s life e.g. a joint replacement surgery, a caesarean, oncology surgery or anything involving an anaesthetist. It is worth discussing options with your intermediary/broker. Worth knowing, though, that many common planned procedures are subject to TRA’s 10-month condition-specific waiting period. (We deal with waiting periods and pre-existing conditions in a separate article.)
If your medical aid is a hospital-only or core option plan, you almost certainly want to consider gap cover at 700%, because these plans tend to pay strictly to scheme rate and leave bigger shortfalls behind. People often pair a core medical aid with TRA’s Super or Absolute Cover Plus precisely so they can keep the medical aid premium down without exposing themselves to surprise bills.
If the tariff percentage is roughly the same between two plans you are weighing up, look at what else is on the page. Vital, Super and Absolute all sit at 700%, but the difference between them on co-payments, oncology cover, MRI sub-limits and maternity benefits is substantial. Someone with young children or a family history of cancer is likely to value Super or Absolute much more than the tariff line alone would suggest.
A Final Note
The 200%, 500% and 700% numbers exist because specialists are allowed to charge whatever they like for a procedure, and your medical aid is allowed to pay only its own rate. Everything else is a gap. Three of TRA’s four plans close that gap to 700%, which covers the great majority of South African specialist accounts in full. The fourth, Basic Cover 300, gives you 300% protection at R99 a month, which is a defensible choice for someone who is mainly worried about the smaller shortfalls.
If you would like a quote, you can request one through our gap cover page. If you would like more background first, our Gap Cover FAQs and our comprehensive gap cover benefits overview both go into more detail.
For a summary, review our 2026 brochure HERE.
Upon application, you receive a full policy document with all of the terms and conditions which apply.
