Some things just work better when they’re together; medical aid and gap cover are no exception.
With medical treatment and specialist costs as high as they are, regardless of your medical aid scheme, there is often a shortfall in covering the full costs charged by healthcare providers.
Without the perfect gap cover policy to pair with your medical aid, members are left with significant payment shortfalls that can cause additional stress during already challenging times.
What Does Medical Aid Gap Cover Do?
Gap cover is a supplementary health insurance product designed to cover the financial gap between what your medical aid pays and what healthcare providers actually charge for medical procedures.
When specialists charge above the medical aid tariff rates, or when your medical aid pays only a percentage of the actual costs, gap cover steps in to cover these medical aid shortfalls. This additional cover ensures you’re not left with substantial out-of-pocket expenses for in-hospital procedures and specific out-of-hospital treatments.
Remember that gap cover is not a substitute for medical aid. Gap cover cannot be used as a replacement for medical aid; it can only work in conjunction with your existing medical aid membership to provide additional financial protection.
Choosing the Best Gap Cover for YOUR Medical Aid
There are plenty of medical aid providers in South Africa. When looking for the best gap cover plan to complement your medical aid cover, consider the following:
1. Coverage Limits and Benefits
Look for plans that offer the overall annual limit, as it should be sufficient to cover major medical expenses, while the policy benefits should match your healthcare requirements.
2. Waiting Periods
Understanding waiting periods is crucial when selecting your gap cover provider. Most plans include a general waiting period for specific conditions and procedures. Pre-existing conditions may have extended waiting periods, so keep this in mind when making a decision.
3. Medical Aid Compatibility
Ensure your chosen gap cover works effectively with your specific medical aid scheme. Different medical aid schemes have varying tariff structures, and your gap cover should complement these effectively.
The Perfect Gap Cover for Major Medical Aid Schemes
Every medical aid will require a different level of gap insurance to ensure shortfalls are sufficiently covered. TRA (Total Risk Administrators) offers comprehensive gap cover and tiered plans to suit your budget.
| Medical Aid Scheme | Coverage Limitations | Common Gap Areas | Why Gap Cover Becomes Necessary |
| Discovery Medical Aid | • 23 plan options with varying benefit levels• Strong hospital cover but with predetermined tariff limits • Co-payments are required on most plans • No overall limits on most plans, but specialist rates are capped | • Specialist fees above tariff rates • Co-payments for scans and procedures • Day clinic and scope procedures • Oncology treatment costs | Discovery pays out well, but specialists often charge 200-500% above their tariff rates, leaving the possibility of shortfalls |
| Momentum Medical Aid | • Range from basic hospital-only to comprehensive cover • Ingwe option limited to PMB and selected networks • Medical Scheme Rate (MSR) caps on specialist fees • Varying day-to-day benefits by plan level | • In-hospital specialist charges above MSR • Emergency trauma costs • Prostheses and specialised equipment t• Private ward upgrades | Even comprehensive plans have MSR limitations that don’t match private healthcare pricing |
| Bestmed Medical Aid | • Self-administered with network and non-network options • Entry-level plans are limited to designated providers • Comprehensive plans still have tariff restrictions • Good chronic and PMB cover, but gaps in specialist care | • Non-network specialist consultations • Advanced diagnostic procedures • Specialist procedures outside the network • Premium facility usage | A large scheme with conservative tariff rates creates gaps when using premium private healthcare |
| Bonitas Medical Aid | • Established provider with traditional benefit structures • Network-based options with a penalty for non-network use • Medical Scheme Rate caps below market pricing • Strong PMB cover but limited specialist tariffs | • Specialist consultations above scheme rates • Non-network facility usage • Advanced procedures and technology • Emergency private hospital treatment | A conservative tariff approach means significant gaps when accessing premium private care |
| GEMS Medical Aid | • Government employee scheme with public sector focus • Limited private sector tariff rates • Structured benefit options but conservative pricing | • Private specialist consultations • Private hospital procedures • Advanced diagnostic imaging • Non-PMB treatments in the private sector | Public sector pricing model creates significant gaps when accessing private healthcare |
| Medshield Medical Aid | • Predetermined tariff schedule often below market rates • Limited specialist fee coverage • Focus on cost containment through tariff controls • Network preferences to manage costs | •Market-related specialist fees • Premium facility charges • Advanced procedures and technology • Emergency private treatment | Conservative predetermined tariffs don’t keep pace with healthcare inflation |
Gap Cover Saves The Day
Gap cover, also known as medical expense shortfall cover, provides crucial financial protection. Having appropriate gap cover ensures you can access necessary medical care without worrying about extensive shortfall expenses.
The right gap cover plan protects you from unexpected medical expense shortfalls while ensuring you receive quality healthcare from your preferred healthcare providers. Whether you need coverage for routine procedures, emergency treatment, or significant medical events, gap cover provides the peace of mind that comes with comprehensive financial protection.
The perfect gap cover plan should offer comprehensive protection across multiple areas:
In-Hospital Coverage
Gap cover plans typically provide substantial coverage for in-hospital procedures, including surgical fees, anaesthetist costs, and specialist consultations during hospital admissions. This coverage extends to various medical procedures that may not be fully covered by your medical aid scheme.
Out-of-Hospital Benefits
Modern gap cover options include coverage for specific out-of-hospital treatments, including specialist consultations, diagnostic procedures, and certain procedural treatments that occur outside hospital settings (but are still paid from the major medical / risk/ in-hospital medical aid benefit).
Co-Payment Cover
Many medical aid schemes require members to make co-payment contributions. Quality gap cover plans include co-payment cover to eliminate these additional costs, particularly for cancer-related treatments and specific chronic conditions.
Additional Benefits
Comprehensive gap cover plans often include lifestyle benefits, travel benefits, accidental death cover, and family cover options. Some plans also provide coverage for cosmetic breast reconstruction following medical procedures and dental reconstruction after accidents.
TRA’s Gap Cover Plans
According to independent review platforms like Hellopeter, TRA was ranked #1 Gap Cover provider in South Africa in 2024 and #2 in January 2025. TRA offers four scaling gap cover products starting from R99 per month, ensuring there’s an affordable option for every budget. Some benefits are mentioned below. These are product option dependent:
- Tariff shortfalls on in-hospital services (up to 700% above the medical aid tariff)
- Co-payments for scopes, scans, oncology, and certain day clinic procedures
- Shortfalls for specialist consultations (including some out-of-hospital consultations related to certain in-hospital procedures)
- Sub-limit gaps on prostheses, scopes, and high-cost treatments
- Authorised dental procedures performed in-hospital
- Oncology extender benefits, including new-tech treatment support
- Casualty unit cover for accident-related visits (adults and children)
- Private ward cover (childbirth and non-childbirth, within set daily limits)
- Maternity follow-up consultations
- Accidental death benefit and policy continuation on the passing of the main member due to an accident
- Travel insurance for policyholders under the age of 71
- Access to Home Drive, trauma counselling, nurse support, and a 24/7 emergency line via TRA Assist mobile app
Note: All gap cover policies are subject to an annual limit of R 219 845 per insured person in 2025 (adjusted annually)
Making Your Decision
To find the best gap cover for medical aid for your situation:
- Assess Your Medical Needs: Consider your current health status, family medical history, and potential future medical requirements.
- Review Your Medical Aid: Understand the limitations, co-payment requirements, and common areas of shortfall of your medical aid scheme.
- Compare Coverage Options: Evaluate different gap cover plans based on coverage limits, benefits, and costs.
- Consider Individual vs. Family Coverage: Determine whether individual coverage or family coverage provides better value for your situation.
- Read Policy Documents: Carefully review all the policy benefits, exclusions, waiting periods, and claim procedures.
Get The Perfect Gap Cover For Your Medical Aid
Don’t wait for a medical emergency to realise the importance of comprehensive gap cover.
Contact Total Risk Administrators today to discuss your gap cover options and find the perfect plan that complements your medical aid membership.
With TRA’s gap cover plans, you are protected against unexpected medical costs.
Visit our Gap Cover page to get started with one of the best gap cover providers in South Africa.
