Medical aid is not the safety net most members think it is. Even on a comprehensive plan, healthcare providers often charge more than what your medical aid pays for a procedure, and the difference then sits with the member to cover, not the scheme. That difference is known as a shortfall, and it’s what gap cover exists to assist with.
The Meaning of Gap Cover in South Africa
Gap cover is a short-term health insurance policy, it is not a medical aid scheme nor a medical scheme benefit. It only pays out when your medical aid settles a claim but doesn’t cover the full amount healthcare providers charge for treatments like in-hospital procedures, cancer treatment, or specialist consultations. It sits alongside your medical scheme rather than replacing it, and it’s regulated separately under the Demarcation Regulations issued in terms of the Medical Schemes Act, alongside the Insurance Act.
That regulatory separation is why gap cover providers manage risk differently to medical schemes. Most gap cover policies apply their own general waiting period, plus condition-specific waiting periods, before certain claims are paid, and pre-existing conditions can affect what’s covered in the first year.
Why You Need Gap Cover in South Africa: 5 Reasons
1. Healthcare providers often charge above medical aid rates
In South Africa, specialists are free to set their own fees. This has seen many specialists charge above the predetermined tariff that a medical scheme reimburses for specific medical treatment. The result is a tariff shortfall, billed directly to the member, that can run into thousands of rands for a single procedure.
Read more on: How gap cover saved a new mom R38,000 on her hospital bill after giving birth
2. Co-payments are built into most medical scheme rules
Many schemes apply compulsory co-payments for specific procedures, from scopes to CT scans, or penalty co-payments for using a non-network hospital. These are standard scheme terms, not exceptions, and most gap cover plans cover them.
3. In-hospital procedures generate the biggest medical aid shortfalls
A single hospital admission can involve a surgeon, anaesthetist, radiologist, and pathologist, each billing separately. Gap cover is built to pay out against exactly this kind of in-hospital cost gap. Medical aid will pay their contribution first, and gap cover will cover the shortfall (up to the annual limit).
4. Sub-limits and annual limits catch members off guard
The saying “know your limits” is true here too. Reading the fine print and understanding what is covered and how it is covered can be the difference between an approved and rejected claim.
Common scheme restriction | What it means |
A cap on a specific benefit category (e.g. internal prosthesis) | |
A ceiling on total claims paid per person or family per year |
5. Out-of-hospital and lifestyle benefits are often excluded
Accidental dentistry, trauma counselling, and certain out-of-hospital treatments fall outside standard medical aid cover on many plans. Depending on the policy, gap cover benefits can extend into these areas too.
Choosing the Best Gap Cover Provider in South Africa
Gap Cover options aren’t priced or structured the same but they do have the same goal: to protect you from unexpected medical expenses and shortfalls.
Finding the best gap cover plan or provider won’t eliminate every medical shortfall, and it won’t be a substitute for adequate medical aid coverage. However, paired with the right scheme, the right gap cover will settle the difference between what your scheme pays and what your provider bills.
Total Risk Administrators (TRA) gap cover offers peace of mind, covering medical aid shortfalls and offering additional benefits for their customers.
