FAQ's

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:

• The claim from the service provider.
• The first two pages of the hospital account that show the hospital event’s admission and discharge dates.
• The medical aid statement showing the payment of the service provider claim and the reason for the short payment.
• You can email these claims documents to claims@totalrisksa.co.za or submit them via our website, www.totalrisksa.co.za or our mobile app, TRA Assist.
• Alternatively, you can contact TRA directly at +27 (11) 372 1540. One of our highly qualified and friendly claims specialists will gladly assist.

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 R210 580 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.