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Gap Cover is an insurance policy that covers the difference between what your medical aid pays and what service providers charge for in-hospital expenses.
All of our TRA Gap Cover Policies:
Provide benefits for a policyholder and their spouse and those financially dependent on them (child/children and/or aged parents) who are covered on one policy of a registered medical aid scheme. Subject to proof of membership and the premium being based on the age of the oldest beneficiary. Members and their dependants can also be on two different medical aids and one Gap Cover Policy but only if they are legally married, or common law partners verified by submission of an affidavit confirming 12 months of cohabitation.
Have no entry age limit.
Claims – Manual and Automatic Processes
The policyholder is responsible for ensuring that claims are submitted and received by TRA within six (6) months from the treatment date. The policyholder should also ensure that TRA has the correct banking details into which we must pay the claim.
Claims – Manual Process
Policyholders need to submit the following:
Claims – Automatic Process
TRA receives claims submitted by selected medical aid schemes on behalf of the policyholder. Should your medical aid company have such an agreement with TRA, it is optional for the policyholder to submit their claim to TRA.
TRA will receive an electronic version of the claim and will process the said claim within seven working days of receipt thereof.
Co-payment and sub-limit claims must always be submitted manually by the policyholder (in addition to all the required claims documentation, please also provide proof of any direct payment/s made to these service providers).
Should a claim be rejected because additional information (e.g. pre-authorisation letter, medical aid statement, doctor’s account or the first two pages of the hospital account) is not received, all the information must be submitted to TRA within 31 days from the date of the request or the claim will be rejected as late/stale in terms of this policy and will not be paid.
Most people purchase medical aid and assume they will take care of all their medical bills. Unfortunately, this is not always true. Medical shortfalls can occur if you need medical care for any reason – accident or illness. You don’t want to add financial worry to the stress of being hospitalised, which is why you need Gap Cover.
Gap Cover ensures you don’t receive a massive bill if there’s a shortfall between what the doctors charge and what your medical aid will pay for in-hospital procedures.
Our TRA Gap Cover policies range in price, starting at just R99 per policy per month. You can compare all of our product option benefits and pricing on the information table on our Gap Cover page.
All of our TRA Gap Cover Policies:
Are not medical aid schemes. The cover is not the same as that of a medical aid scheme. The cover is not a substitute for a medical scheme membership.
Gap Cover:
The shortfall that arises after your medical aid has processed your account and is due to service providers charging above scheme tariff for authorised in-hospital procedures. The cover is limited to a percentage of the original scheme tariff.
When are you not covered under your Gap Cover policy?:
Where your medical aid does not pay their portion of an account first from the Risk or Major Medical benefit. No claims processed from your Scheme’s day to day benefit will be covered – except for the Casualty benefit. (Please check your option benefits in the Schedule).
You can claim from gap cover over the phone, via email, on the website or via the mobile app. Each gap cover provider should provide multiple platforms that policyholders can use to claim. You can claim from TRA be emailing www.claims.totalrisksa.co.za , submitting a claim on our website or via our mobile app called TRA Assist.
Gap cover is used to cover shortfalls when doctors charge above medical aid rates. Gap cover is designed to provide extra protection for those who already have a medical aid. If a procedure or medical expense is covered in full by your medical aid or if your treatment is excluded by your medical aid, then gap cover will not cover the excess costs.
There is no age limit to joining a gap cover policy. The premium is based on the age of the oldest beneficiary for TRA policyholders but gap cover providers do not impose an age limit. It’s important to ensure that you and your dependents are already on a medical aid to be eligible for gap cover regardless of age.
TRA offers the best, most comprehensive and most affordable gap cover in South Africa. We offer comprehensive medical shortfall benefits at affordable rates. We also pay claims of up to an overall annual limit of R219 845 per insured person.
Gap cover is not just valid for hospitalisation. Gap cover covers shortfalls where doctors charge above the medical aid rate for certain procedures performed in the doctor’s rooms – but they have to have been authorised and paid for from the In-Hospital or Major Medical Benefit first.
No, gap cover is not a substitute for medical aid, nor is it a medical scheme. Gap cover cannot provide cover where your medical aid does not pay towards a procedure or covers the full amount.
Gap cover prices vary between the provider you choose, the package you select, and the current cost of your medical aid per month. Contact us for a comprehensive gap cover quote tailored to your needs today.
Gap Cover is an insurance product that helps pay the shortfall between what your medical aid scheme pays and what healthcare specialists charge for certain in-hospital procedures. In South Africa, specialists may charge several times the medical aid tariff, which can leave patients responsible for large out-of-pocket expenses. Gap Cover helps reduce this financial risk by covering some of those shortfalls, subject to the policy terms and annual limits.
Yes. Gap Cover is designed to work alongside a registered medical aid scheme in South Africa. You must already belong to a medical aid in order to take out a Gap Cover policy, as Gap Cover only pays once your medical aid has processed and paid its portion of a claim.
When you receive authorised medical treatment in hospital, your medical aid will first pay its portion of the claim according to its tariff rate. If the healthcare provider charges more than the medical aid tariff, a shortfall may arise. Gap Cover may then help cover part of that difference, depending on the policy terms, limits and conditions.
Many members who belong to a medical aid scheme may benefit from Gap Cover. Many medical aids reimburse healthcare providers according to set tariff rates, but specialists can charge significantly more than those rates. Gap Cover helps protect individuals and families from unexpected medical expenses caused by these shortfalls.
Gap Cover policies may help cover shortfalls for specialist consultation fees during hospital procedures, co-payments required by medical schemes, certain sub-limit shortfalls, and other medical aid tariff differences. The exact benefits depend on the Gap Cover option selected and the applicable policy terms.
Medical aid helps pay for general healthcare costs such as hospitalisation, doctor consultations and medication. Gap Cover is a separate insurance policy that supplements medical aid by helping cover shortfalls when healthcare providers charge more than the medical aid tariff.
The monthly cost of Gap Cover depends on the provider, the type of policy selected, and the number of people covered. Entry-level plans generally offer more affordable premiums, while comprehensive policies provide broader protection against co-payments, sub-limits and specialist tariff shortfalls.
You can submit a Gap Cover claim once your medical aid has processed and paid its portion of the hospital claim. If there is a difference between what the medical aid paid and what the healthcare provider charged, the Gap Cover policy may assist with covering that shortfall according to the policy terms.
Some Gap Cover policies may assist with shortfalls for certain day procedures performed in hospital or approved facilities. However, the cover available depends on the policy option selected and the specific terms and conditions of the insurer.
Gap Cover premiums are generally not tax deductible for individuals. However, Gap Cover may still provide valuable financial protection by helping reduce unexpected medical expenses that medical aid schemes may not fully cover.
TRA processes Gap Cover claim payments three times per week, making it one of the fastest turnaround times in the industry. Members can submit claims and track their progress from submission to payment via the TRA mobile app.
No. Gap Cover only pays the difference when your medical aid has already paid a portion of a hospital claim. If your medical aid does not cover or rejects a procedure entirely, Gap Cover generally will not apply. Gap Cover is designed to cover the shortfall, not to replace medical aid benefits.
Basic Cover 300 is an entry-level Gap Cover option offered by Total Risk Administrators. It is designed to help cover certain shortfalls between what your medical aid pays and what healthcare providers charge for authorised in-hospital procedures.
Basic Cover 300 includes cover for certain medical aid tariff shortfalls, casualty cover for unexpected medical events, and an oncology gap benefit. These benefits are designed to provide affordable financial protection against hospital treatment shortfalls.
The Basic Gap, Casualty and Oncology Gap benefits are subject to an aggregate annual limit of R219 845 per insured person per year, in line with regulatory limits. This limit may change if new regulations are introduced.
Basic Cover 300 may suit individuals or families who want an affordable starting point for Gap Cover. It provides protection against certain medical aid shortfalls without the broader benefits included in higher-tier plans.
Your medical aid first pays its portion of a hospital claim according to its tariff. If a healthcare provider charges more than the medical aid rate, Basic Cover 300 may help cover some of that shortfall, subject to policy limits and conditions.
If you want protection against additional costs such as medical scheme co-payments or certain sub-limits, a mid-level policy like Vital Cover Plus or Super Cover Plus may offer broader protection.
Vital Cover Plus is a mid-level Gap Cover policy from Total Risk Administrators. It helps cover certain medical aid shortfalls during hospital procedures and includes additional benefits such as co-payment cover, sub-limit protection and oncology gap benefits.
Vital Cover Plus includes cover for specialist tariff shortfalls, co-payments required by medical schemes, certain sub-limit shortfalls, casualty unit benefits and oncology gap cover. Eligible in-hospital shortfalls may be covered up to 700% of the medical scheme tariff, subject to policy terms.
The combined benefits under Vital Cover Plus are subject to an aggregate annual limit of R219 845 per insured person per year, in line with current regulatory limits.
Vital Cover Plus may suit individuals or families who want broader protection than entry-level Gap Cover. It provides additional financial protection against co-payments and certain sub-limits that may arise during hospital treatment.
While Basic Cover 300 focuses mainly on tariff shortfalls at 300% of the medical scheme tariff, Vital Cover Plus extends protection to 700% and includes co-payment cover and certain sub-limit protection. If your medical scheme requires co-payments for hospital admissions or you want broader cover against specialist fees, Vital Cover Plus may be the better fit.
Super Cover Plus is an enhanced Gap Cover policy offered by Total Risk Administrators. It provides broader protection against medical aid tariff shortfalls and includes additional benefits designed to reduce the financial impact of hospital treatment.
Super Cover Plus includes cover for theatre and ward fee shortfalls, specialist consultation shortfalls, co-payment cover, sub-limit protection, casualty benefits and oncology gap cover. It also includes additional benefits such as maternity follow-up consultations, accidental death cover and travel benefits.
Yes. Super Cover Plus includes oncology benefits such as oncology gap cover, oncology co-payment protection and an oncology extender benefit, subject to policy terms and limits.
The combined benefits are subject to an aggregate annual limit of R219 845 per insured person per year, in accordance with regulatory limits.
Super Cover Plus may be suitable for individuals or families who want more comprehensive protection than mid-level policies. It includes broader benefits that may help reduce financial exposure during hospital treatment and related medical events.
Super Cover Plus includes additional benefits such as maternity follow-up consultations, travel insurance up to R1 000 000 in emergency medical expenses, and accidental death cover. If you are planning a family, travel regularly, or want added peace of mind beyond standard gap cover, Super Cover Plus offers a broader safety net than Vital Cover Plus.
Yes. TRA allows policyholders to upgrade their Gap Cover plan during the policy year. If your needs change or you want access to broader benefits such as travel cover or dental benefits, you can contact TRA or your broker to discuss upgrading to a higher-tier plan.
Absolute Cover Plus is the flagship Gap Cover policy offered by Total Risk Administrators. It provides the most comprehensive protection against certain medical aid shortfalls and includes an extended range of benefits.
Absolute Cover Plus includes cover for specialist tariff shortfalls, theatre and ward fee shortfalls, co-payment protection, sub-limit cover, oncology benefits, emergency medical services, maternity-related benefits, dental benefits and travel benefits. The policy also includes TRA Assist services.
Yes. Absolute Cover Plus includes oncology gap cover, oncology co-payment cover and an oncology extender benefit, which may assist with certain costs related to cancer treatment.
The combined benefits under Absolute Cover Plus are subject to an aggregate annual limit of R219 845 per insured person per year, in line with current regulatory requirements.
Absolute Cover Plus may be suitable for individuals or families who want the most comprehensive level of Gap Cover protection offered by TRA. It includes the widest range of benefits designed to reduce the financial impact of hospital treatment and related medical expenses.
Absolute Cover Plus is the only TRA plan that includes dental benefits, emergency medical services and the full TRA Assist package. It is designed for individuals or families who want the widest possible protection, including benefits not available on any other TRA plan. If you want a single policy that covers hospital shortfalls, oncology, dental, travel and emergency services, Absolute Cover Plus is the most complete option.
Female Cancer Cover is a specialised insurance policy designed to provide financial support to women diagnosed with certain cancers. The policy pays a once-off lump sum upon confirmed diagnosis, which can be used to help cover treatment costs, recovery expenses or other financial needs.
Female Cancer Cover is designed to provide protection for certain cancers that commonly affect women, including breast cancer and cervical cancer. A diagnosis must be confirmed by evidence of malignancy from a qualified oncologist or pathologist, subject to policy terms.
Once a covered cancer diagnosis is confirmed, the policy pays a once-off lump sum based on the selected cover option. Depending on the plan chosen, payouts can range from R25 000 to R150 000 per unrelated occurrence, subject to the policy terms.
Female Cancer Cover is designed to complement existing medical aid or gap cover, but the policy itself provides a lump sum benefit that can be used for any expenses related to treatment or recovery.
Policyholders may also have access to TRA Assist services powered by MobiMed. These services may include Home Drive transport, a 24/7 panic button, trauma counselling support and mobile claim submissions through the TRA mobile app.
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