Gap cover is a short-term insurance product designed to cover the financial shortfall between what your medical aid pays and the actual costs charged by private healthcare providers. In South Africa, medical aid schemes often reimburse healthcare services at a predetermined rate, known as the medical scheme tariff (MST). However, specialists and hospitals may charge significantly more than these medical scheme rates, leaving patients responsible for the difference.
Total Risk Administrators (TRA) offers gap cover insurance to protect you against these unexpected medical shortfalls and expenses.
How Does Gap Cover Work?
Depending on your plan, your medical aid covers a portion of the costs based on its pre-determined tariff when undergoing medical treatment, especially in-hospital procedures. If the specialists charge more than this pre-determined amount, you would be liable for the balance.
TRA’s policies address this financial “gap” by covering the shortfall, ensuring you’re not paying out of pocket for the difference. At a relatively low premium (in comparison to medical aid schemes), it is important to note that gap cover is not a substitute for medical aid but rather a complementary product that strengthens you and your family’s overall medical cover. You have to be on a registered medical aid plan, registered with the South African Council for Medical Schemes (the CMS), to qualify for gap cover. Health insurance or Primary Care products do not qualify.
Always refer to your medical aid plan policy to understand your medical scheme benefits and tariffs.
FAQs on Gap Insurance For South Africans
“What is gap cover insurance, and do I need it if I already have medical aid?”
Gap cover is a supplementary insurance product that covers the difference between what your medical aid pays and what healthcare providers charge, particularly for in-hospital procedures. If your medical scheme membership doesn’t cover the full amount, gap cover saves you from paying the shortfall out of your own pocket.
“Is gap cover a substitute for medical aid?”
No. Gap cover is not a substitute for medical aid. It is an insurance policy that works alongside your medical aid to provide additional financial protection, especially during hospital procedures.
“What does gap insurance typically cover?”
Gap cover usually includes:
- Tariff shortfall cover (the difference between medical aid rates and actual costs)
- Co-payment cover
- Sub-limit cover
Depending on the provider, some policies may include benefits such as travel insurance, casualty cover and policy extenders.
“Are there waiting periods for gap cover?”
Typically, yes. Common waiting periods follow the Council for Medical Schemes’ suggestion of:
- A 3-month general waiting period.
- A 12-month pre-existing condition or condition-specific waiting period.
TRA’s waiting periods are different. TRA does not apply general waiting periods. TRA offers a 10-month waiting period for condition-specific conditions like hernias, back issues, and pregnancy. Lastly, TRA only applies a 6-month waiting period for more general pre-existing conditions.
“How much does gap cover cost in 2025?”
Gap cover pricing is provider-dependent. TRA’s 2025 plans start from R99 per month for individuals and range to R770 per month for comprehensive family and over-65 options.
“Can I get gap cover for my whole family?”
Typically, gap cover policies offer family options; however, this depends on the provider. TRA offers family plans that extend benefits in cases where all of the family members are on one registered medical aid policy together (dependents); or, if a couple is married/ common law partners.
“Does gap cover apply to out-of-hospital treatments?”
Gap cover primarily applies to in-hospital treatments. However, depending on the policy, some plans may cover specific outpatient procedures (e.g., casualty ward visits).
“Can I have gap cover if I’m over 65?”
It depends on the provider. In the case of TRA, yes. TRA offers gap cover for individuals over 65. However, a higher premium then applies.
“What are some common exclusions in gap cover policies?”
Exclusions when it comes to gap cover/insurance can include:
- Cosmetic surgery (unless cosmetic breast reconstruction surgery is covered for women undergoing oncology treatment)
- Experimental treatments
- Specialised procedures (unless covered explicitly)
Note: Always check the complete list of exclusions and inclusions in your insurer’s policy.
TRA’s Policy Options
Total Risk Administrators (TRA) offers a range of policies tailored to meet diverse needs and budgets. Our 2025 offerings include:
Basic Cover 300
- Coverage: Up to 300% of the medical scheme’s tariff for in-hospital shortfalls.
- Additional Benefits: Casualty cover and a separate oncology gap cover benefit.
- Premiums:
- Individual: R99 p/m
- Families: R180 p/m
- Over 65’s: R360 p/m
Sign up for Basic Cover today.
Vital Cover Plus
- Coverage: Up to 700% above the medical scheme tariff.
- Additional Benefits: Co-payment cover, sub-limit cover, and a separate oncology benefit for gap and certain co-payments.
- Premiums:
- Individual and Families: R360 p/m
- Over 65’s: R540 p/m
Sign up for Vital Cover Plus today.
Super Cover Plus
- Coverage: Comprehensive coverage up to 700% above the medical scheme tariff.
- Additional Benefits: Enhanced oncology benefits, co-payment cover, and sub-limit cover.
- Premiums:
- Individuals: R380 p/m
- Over 65’s: R570 p/m
Sign up for Super Cover Plus today.
Absolute Cover Plus
- Coverage: Extensive benefits, including unlimited oncology extender cover and coverage up to 700% above the medical scheme tariff.
- Additional Benefits: Co-payment cover, sub-limit cover, and more.
- Premiums:
- Individuals: R620 p/m
- Over 65’s: R770 p/m
Sign up for Absolute Cover Plus today.
Note: For detailed information on each plan, refer to the TRA 2025 Gap Cover Brochure.
Understanding Waiting Periods
When signing up for a TRA policy, certain waiting periods may apply:
- General Waiting Period: TRA does not impose a general three-month waiting period on its gap cover products.
- Condition-Specific Waiting Period: A 10-month waiting period applies to specific conditions, such as spinal surgeries, hernia operations, and pregnancy-related procedures.
- Pre-Existing Conditions: A six-month waiting period is applicable for any pre-existing medical conditions.
For a comprehensive list of waiting periods and applicable conditions, consult the TRA 2025 Gap Cover Pricing Plans.
Why Choose Total Risk Administrators (TRA)?
TRA stands out as one of the best gap covers in South Africa for several reasons:
- Comprehensive Coverage: Addressing both in-hospital and certain out-of-hospital shortfalls.
- Affordable Premiums: Starting from as low as R99 per month, there is a plan for everyone.
- Value-Added Services: Including emergency assistance, travel insurance, and more.
- No General Waiting Period: Immediate access to benefits, subject to specific conditions.
With TRA Gap Cover you have an affordable answer to potential financial shortfalls, ensuring that unexpected medical expenses don’t leave you forking out money when you don’t have it or deter you from seeking medical help when you need it.
Rest easy knowing TRA has your back. Sign up today.
For more information or to select the right policy for you, visit Total Risk Administrators or visit our Medical Gap Cover page here.
