Changing your medical aid plan is a big decision, and many South Africans face it at some point for various reasons, including seeking more comprehensive benefits, balancing their budget, or finding a plan that better suits their family’s healthcare needs.
But here’s a question that often gets overlooked: what happens to your gap cover when you change medical aid?
Your gap cover policy and medical aid work together to protect you from unexpected medical bills. When you make changes to one, it’s crucial to understand how it affects the other. This guide explains exactly what you need to know to keep your cover intact and avoid any gaps in protection.
Do I Need to Cancel My Gap Cover When I Switch Medical Aids?
This is one of the most common questions we receive, and the short answer is: no, you don’t need to cancel your gap cover.
Gap cover is a separate non-life based insurance policy that works alongside your medical aid. It remains active regardless of which medical scheme you belong to, provided you continue to:
- Maintain an active membership with a registered medical aid scheme
- Keep paying your gap cover premiums
- Notify your gap cover provider of the change
Your gap cover doesn’t automatically cancel when you switch medical aids. However, you do need to inform your provider so they can update your details and continue processing any future claims correctly.
Does My Gap Cover Transfer to My New Medical Aid?
Gap cover doesn’t “transfer” in the traditional sense because it’s not linked to a specific medical aid scheme. It’s a standalone insurance policy that provides financial protection against tariff shortfalls and co-payments, no matter which medical aid you’re on.
Think of it this way: your medical aid covers the base cost of medical procedures, while your gap cover steps in to pay the difference between what your medical aid covers and what healthcare providers actually charge.
As long as you remain a member of a registered South African medical scheme and continue paying your premiums, your gap cover remains active. The key is simply to update your gap cover provider with your new medical aid details so they can process claims correctly.
What Do I Need to Tell My Gap Cover Provider?
When you change medical aid, you’ll need to notify your gap cover provider with the following information:
- Your new medical scheme name
- Your new membership number
- The effective date of your new medical aid
- Updated details for the main member, spouse, and any dependents
- Any changes to your contact details or banking information
TRA makes this process simple. You can update your details by contacting our membership department – membership@totalrisksa.co.za ; 011 372 1540. You can also make certain updates which are sent to our membership team via your mobile app, TRA Assist. Keeping your records current prevents delays when you need to submit a claim.
Will I Have New Waiting Periods on My Gap Cover?
If you’re staying with the same gap cover provider, you generally won’t face new waiting periods. You’ve already served your initial waiting periods when you first took out the policy, and changing your medical aid doesn’t reset these.
Your continuous gap cover membership is maintained, which means you remain fully covered for the benefits outlined in your policy.
However, if you decide to switch to a new gap cover provider at the same time as changing your medical aid, waiting periods may apply. This is an important distinction to understand.
What If I Downgrade My Medical Aid?
This is where gap cover could become even more essential.
Many South Africans downgrade their medical aid plan to save on monthly premiums, especially when budgets are tight. While this can provide short-term relief, it’s important to understand that lower-tier plans come with drawbacks:
- Higher co-payments and additional co-payment requirements
- Increased tariff shortfalls when you see a specialist
- Limited coverage for certain medical procedures
- Network restrictions that limit your access to preferred doctors
- Reduced benefits for chronic conditions and cancer treatment
When you downgrade your medical aid, the gap between what your scheme pays and the actual cost of treatment often widens. In short, you could end up paying more money in the long run because you do not have adequate gap cover in place.
Consider upgrading your gap cover when you downgrade your medical aid. This strategy can help you maintain comprehensive protection while still achieving cost savings on your overall healthcare spend.
What If I Upgrade My Medical Aid?
Upgrading to a plan with more comprehensive benefits is excellent news for your health and well-being. But even with a higher-tier medical aid, gap cover remains valuable.
Here’s why: even comprehensive medical aid plans don’t cover 100% of specialist charges. Healthcare providers in South Africa can charge up to five or six times the medical scheme rate, and your medical aid will only pay up to a certain limit.
The difference still comes out of your pocket, unless you have gap cover to fill the shortfall.
When you upgrade your medical aid, take the opportunity to review your gap cover policy. You may find that your current level of gap cover still meets your needs, or you might want to adjust it based on your new medical aid’s benefits.
Most medical aid plans only allow changing options once a year, usually with the year-end premium renewal period e.g. effective 1 January of the year for that year.
Can I Upgrade or Downgrade My Gap Cover?
This will depend on your gap cover provider’s policy rules. With TRA, you can downgrade product options any time during the year. You can only upgrade once a year, with the 1 January renewal period.
With TRA, you can move between our four gap cover options:
- Basic Cover 300 — Entry-level cover at an affordable premium
- Vital Cover Plus — Enhanced benefits for growing families
- Super Cover Plus — Comprehensive cover with additional benefits
- Absolute Cover Plus — Our premium offering with maximum protection
If your healthcare needs have changed, or if you’ve adjusted your medical aid plan, it makes sense to review whether your current gap cover level is still right for you. Contact your provider to discuss your options and find the right balance between cover and cost.
Avoiding a Break in Cover
One of the biggest risks when changing medical aid is creating an accidental gap in your cover. This can leave you vulnerable if you need treatment during the transition period.
Here’s what you need to know:
- Your gap cover requires an active medical scheme membership to pay claims
- If your medical aid lapses, even briefly, your gap cover claims may not be paid
- Ensure your new medical aid is confirmed and active before cancelling your old one
- Never belong to two medical aids at the same time, as this is illegal in South Africa
Tip: Give your current medical scheme the required notice period (usually one calendar month), and time your new membership to start immediately after the old one ends. This ensures continuous cover and peace of mind.
Switching Gap Cover Providers: What to Know
While you don’t need to change gap cover providers when you switch medical aids, you might decide it’s a good time to review your options.
Here’s what to consider if you’re thinking about switching gap cover providers:
- You can switch gap cover providers at any time
- New waiting periods may apply with a new provider
- Pre-existing conditions may be subject to a waiting period
- TRA offers reduced or waived waiting periods if you provide proof of prior gap cover within 90 days
- Compare the policy benefits, not just the premiums
If you’ve been with a gap cover provider that hasn’t met your expectations, or if you’re looking for better benefits, switching to TRA could be the right move. We’re known for our fast claims turnaround and excellent service, with payment runs three times a week.
What Gap Cover Does and Doesn’t Cover
To make the right decisions about your gap cover, it’s important to understand what it covers and what falls outside its scope.
Gap cover typically pays for:
- Tariff shortfalls when specialists charge above the medical aid rate
- Co-payments and deductibles applied by your medical aid
- In-hospital procedures and related specialist fees
- Certain out-of-hospital procedures like MRI and CT scans (depending on your plan)
- Shortfalls on prescribed minimum benefits (PMBs) where your medical aid hasn’t fully covered the cost
Gap cover does not pay for:
- Procedures your medical aid doesn’t cover at all
- GP visits and routine day-to-day expenses
- Cosmetic surgery and elective procedures not authorised by your medical aid
- Claims where your medical aid has already paid the full amount
- Treatment received while your medical aid membership was inactive
Understanding these limits helps you make informed decisions and avoid disappointment when you need to claim.
Checklist: Changing Medical Aid With Gap Cover
Use this checklist to ensure a smooth transition when changing your medical aid:
- ☐ Research and compare new medical aid options
- ☐ Confirm your new medical aid application has been accepted
- ☐ Give proper notice to your current medical scheme
- ☐ Ensure there’s no break in medical aid cover
- ☐ Notify your gap cover provider of the change
- ☐ Provide your new medical scheme name and membership number
- ☐ Update details for your spouse and any child dependents
- ☐ Review your gap cover level to see if you need to upgrade or adjust if possible
- ☐ Keep proof of continuous gap cover membership
- ☐ Confirm your gap cover account details are correct for any claims
Completing these gap cover steps ensures you remain protected throughout the transition and beyond.
TRA Gap Cover: Flexibility When You Need It
At Total Risk Administrators, we understand that life changes, and your healthcare needs change with it. That’s why we’ve designed our gap cover policies to be flexible and straightforward.
Here’s what makes TRA different:
- No general waiting period: Many policyholders qualify for immediate benefits
- Easy updates: Simply contact us when you change medical aid
- Multiple plan options: From R99 per month, you can choose the level of cover that suits your needs and budget
- Fast claims processing: We run payments three times a week, so you’re not left waiting
- Excellent service: We’re consistently rated among the top gap cover providers in South Africa
Get in Touch With TRA
If you’re changing medical aid and have questions about your gap cover, we’re here to help. Our team can guide you through the process, update your details, and ensure you have the right level of cover for your needs.
Contact TRA to speak with a consultant, or apply online to get a quote today.For more information on switching medical aids, read our complete guide: Tips for Switching Medical Aids in South Africa.
