Many South Africans are unaware of what medical gap cover is or why it’s essential. A common misconception is that medical aid covers 100% of in-hospital procedures, but this isn’t true. Medical aids only pay up to a set tariff rate, leaving you responsible for any shortfall when doctors charge above this amount. These gaps can add up to thousands of rands.
With rising healthcare costs, gap cover from Total Risk Administrators protects you and your family from unexpected out-of-pocket medical expenses.
What is Gap Cover?
Gap cover is an insurance policy designed to pay for the “gap” or medical shortfalls between the rates charged by private healthcare providers and what your medical scheme membership will cover. It is designed to cover in-hospital procedures and certain defined treatments, but does not cover GP visits, routine check-ups, or everyday medical costs.
Depending on which policy you choose, gap cover may cover all or part of the difference between the amount your registered medical aid scheme agrees to pay and the full cost charged by the medical facility. Gap cover is not a substitute for medical aid but a supplementary insurance intended to augment your existing registered medical aid. Gap cover provides security regardless of the medical aid plan or option you have selected.
Who Can Apply for Gap Cover?
Anyone who is a member of a registered medical aid scheme in South Africa can apply for gap cover insurance. Whether you are the main member or have dependants on your policy, gap cover offers financial protection for your family.
Some gap cover plans allow for family coverage, including spouses and children, while others may be limited to individuals only. TRA offers policies that cover the insured person and their dependents, subject to age requirements, medical aid membership, and policy terms.
What Does Gap Cover Pay For?
Gap cover benefits extend to tariff shortfalls on payments for treatments related to several critical illnesses and hospital procedures, including:
- Oncology treatment and cancer treatment (gap cover can cover co-payments and additional costs once medical aid limits are reached)
- Breast cancer surgery and unaffected breast procedures
- Cosmetic surgery (for dental reconstruction or breast reconstruction following a diagnosis)
- Renal problems
- Strokes and comas
- Heart attacks
- Trauma-related hospital treatments
Certain costs may also be covered, including co-payments, private ward upgrades, and lifestyle benefits such as trauma counselling. The cover benefits vary depending on your policy terms and are subject to an annual limit per insured person.
Annual Limits and Exclusions
Gap cover policies typically have an annual limit on the maximum amount they will pay for covered expenses. Policies are subject to overall annual limits, which for 2026 is R219,845 per insured person..
Common exclusions in gap cover policies include pre-existing conditions and certain procedures that may have specific waiting periods. Many gap cover plans have exclusions and waiting periods for pre-existing conditions, including pregnancy. TRA does not impose a general waiting period on most claims, though waiting periods may apply for specific conditions. Always refer to the full list of exclusions and limitations in your policy terms.
Gap Cover Pricing
Gap cover plans in South Africa vary in price, starting from around R99 to R282 per month, depending on the level of cover and benefits included. TRA has tailored four premium product options that won’t break the bank:
- Basic Cover 300 – ideal for the main member and family seeking essential protection
- Vital Cover Plus – includes additional co-payment cover and benefits
- Super Cover Plus – comprehensive cover for hospital and out-of-hospital procedures
- Absolute Cover Plus – maximum protection with extensive cover benefits, including accidental death cover
Why Choose TRA?
Since its inception in 1999, Total Risk Administrators has held the belief that enhanced service delivery, through experience and premeditated product design, has led to ongoing support for its gap cover products. TRA’s purpose is entrenched through our staff’s professionalism and values, ensuring an enhanced gap cover experience for every policyholder.
Guided by level-headed but ambitious managerial staff, TRA aims to provide the most equitable gap cover product offering to all stakeholders. They strive to give the policyholder a voice and create the ultimate customer experience throughout the life of the relationship.
How to Claim
The claims process involves submitting a claim form and supporting documents to your gap cover provider for reimbursement. Simply attach your medical aid statement showing what your medical aid pays, along with the treatment details, and submit to TRA. Payments are processed quickly, reducing financial stress during an already difficult event.
You are limited to one claim per treatment or procedure, and savings from your medical aid do not generally qualify for gap cover claims. Voluntary use of non-network providers may also affect your cover.
Don’t Let Medical Shortfalls Catch You Off Guard
Even with excellent medical aid, you are likely to find yourself having to fill the gap, which could potentially cost thousands of rand. Don’t add financial stress to the trauma of being hospitalised. Rest assured, the gap is covered with Total Risk Administrators. Ready to apply online? For more information or questions regarding gap cover, visit www.totalrisksa.co.za or contact one of our helpful specialists and brokers here.
