In general, we all aim to ensure that our health, and that of our loved ones, is looked after. However, the past few years have shown that there are no guarantees regarding healthcare costs or medical cover. For many South African families, unexpected medical expenses can quickly become a financial burden without the right safety net.
This is where gap cover comes in.
Gap cover insurance covers the in-hospital shortfalls of medical aids when they don’t finance everything a client needs. This gap cover insurance can be crucial since we can never predict when we will need it most, especially during a medical emergency. Gap cover insurance is designed to protect you from unexpected medical expenses.
Why Do We Need Gap Cover?
The cost of private healthcare is increasing rapidly due to South Africa’s rising medical inflation. Also, no South African law governs what doctors can charge, which is why gap cover is critical to protect your family from financial risks.
According to BusinessTech, medical aid schemes in South Africa have announced significant price hikes for plans starting January 2026, averaging 10.7% across 12 of the biggest schemes – far higher than inflation, which is expected to average below 4%. Medical aid contributions have skyrocketed over the past few years at a rate double that of inflation.
Gap cover offers a range of benefits, especially in the South African context. Gap cover providers step in to offer tailored gap cover solutions, ensuring clients across the country are covered from every angle and protected against specialist charges and other medical expenses not fully covered by medical schemes. These tailored gap cover solutions address the specific needs of South African families.
As a whole, gap cover goes hand in hand with medical aid, working to cover the shortfalls that occur during your time of need. When your medical aid covers only a portion of the bill, gap cover pays the difference, ensuring your financial well-being remains intact.
Gap Cover in South Africa
Public healthcare in South Africa is notoriously understaffed and overcrowded. According to a recent Stats SA survey, only approximately 15.5% of South Africans have access to medical aid. The highest medical aid coverage rates were found in the Western Cape (25.4%) and Gauteng (21.3%), while the lowest were in Limpopo (10.0%) and KwaZulu-Natal (10.2%).
This means roughly 84% of the population relies on public health facilities, as confirmed by President Ramaphosa in May 2024. For medically insured South Africans, the rising costs of healthcare funding present additional challenges.
The Council for Medical Schemes (CMS) has noted that “South African consumers remain under serious financial pressure due to high interest rates over the past years.” The cost-of-living crisis, driven by stubborn inflation and high household debt, could affect members’ ability to afford medical scheme premiums. This increased demand for affordable healthcare options has expanded thegap cover market significantly.
Obviously, private healthcare remains the safest option in South Africa, with access to private hospitals and quality medical care. But how do you afford private healthcare without breaking the bank? Again, gap cover might be able to save the day.
Whilst gap cover is not a substitute for a registered medical aid scheme, policyholders can select a more affordable medical aid product that doesn’t fully cover all costs and have a gap cover policy with myriad additional benefits to complement it. This approach provides financial stability while ensuring comprehensive medical aid coverage.
This option is often cheaper than selecting a medical aid that offers premium coverage. Not only will you save money through smart financial planning, but you will also have peace of mind knowing that you and your family are securely covered in the event of a medical emergency. Many South Africans are discovering that the best gap cover plan combines affordability with extensive benefit options. Gap cover insurance has become essential for maintaining adequate medical aid coverage without overspending.
Gap Cover and Oncology Benefits
Most medical aids offer a certain level of coverage for oncology, after which the patient is responsible for the remaining cancer treatment costs. The CMS Industry Report 2024 confirms that total healthcare expenditure on benefits paid increased to R259.3 billion, up by 8.52% from 2023, with hospital expenditure remaining the dominant cost driver at 35.95% of total benefits.
Gap cover providers like TRA offer oncology benefits that help bridge financial gaps that can occur during cancer treatment. All gap cover benefits are reviewed regularly, and we are constantly considering how best to serve our policyholders in their time of need. Our gap cover products are designed with your well-being in mind.
Take a look at our 2026 brochure to see what this benefit entails and how it could help you avoid financial hardship. Speaking with a financial advisor can also help you understand how gap cover fits into your overall financial planning strategy.
Co-Payment Benefits
Co-payments are set amounts required by a medical aid to be paid by the client. The co-payment amount will be fixed for specific procedures, treatments, and medical requirements, differing from case to case. Many medical schemes now introduce co-payments to manage rising costs.
Co-payment benefits vary depending on your gap cover provider and will need to be weighed when considering who will be offering the service. Co-payments have become more expensive and common due to rising private healthcare costs and broader healthcare sector costs.
The ever-increasing cost of healthcare is another reason why it is essential to have a gap cover provider that offers comprehensive benefits and helps protect against unnecessary costs. Gap cover insurance provides additional coverage that can help the average person manage these financial risks. This additional coverage ensures you’re not left with unexpected bills.
Gap Cover and Maternity Ward Benefits
Not all medical schemes cover maternity benefits, but it is crucial for pregnant women to be covered when they need healthcare more than ever. Gap cover for pregnancy can help bridge this gap, providing a safety net for growing families.
Maternity benefits include antenatal consultations, ultrasound scans, blood tests, and, in some cases, antenatal classes. When looking for gap cover to provide maternity benefits, you must note that most providers apply waiting periods of around 10–12 months for maternity-related claims.
If you and your partner are considering having children soon, selecting a gap cover policy earlier rather than later is best to ensure that your family is securely covered. Understanding the waiting periods and policy limits is essential when planning for this significant life event.
What Is an Annual Aggregate Limit?
An annual aggregate limit is a maximum amount a policyholder may be reimbursed for by their gap cover provider within a given year. This limit aims to ensure all covered losses are taken care of financially, providing comprehensive protection against significant medical expenses. TRA’s aggregate annual limit is R219,845 per insured person.
The demarcation regulations, governed under the Short-Term Insurance Act, determine the annual aggregate limit through a definitive table of figures. This ensures that gap cover providers offer a consistent and stable limit that aligns with South Africa’s inflation rate, protecting policyholders from the erosion of their benefit value over time.
The Future of Gap Cover
The future of gap cover is evolving to merge comprehensive benefit options with the realities many South Africans face in the current economic climate. As discussions around National Health Insurance continue and the gap cover market expands, having the right cover becomes increasingly important for healthcare funding. The future of gap cover in South Africa looks promising as more people recognise its value.
With the CMS regulating 71 medical schemes serving more than 9.1 million beneficiaries, and hospital costs per admission increasing by 9.88% according to the 2024 Industry Report, the need for gap cover in South Africa has never been clearer. Medical aid schemes continue to face pressure from rising healthcare costs. The expanding list of benefits offered to clients makes it easier to make long-term decisions about your family’s healthcare.
Gap cover is becoming a necessity in South Africa, and its benefits are becoming increasingly relevant. Whether you need protection against specialist charges, help with co-payments, or coverage when your medical aid doesn’t fully cover a procedure, gap cover provides the financial protection South African families need. Contact TRA today to find the best gap cover plan for your needs and discover how our gap cover products can help protect your family’s financial future. Our range of gap cover products offers something for every budget and healthcare need.
