Medical gap insurance is essential for South Africans who want comprehensive coverage and financial protection against medical expense shortfalls. Even with a registered medical aid scheme, many members face unexpected costs for in-hospital procedures, specialist treatments, and co-payments.
This article explains how gap insurance works, what it covers, and why it’s a must-have for anyone on a medical aid plan.
What Is Medical Gap Insurance?
Medical gap insurance (also called gap cover) is a short-term insurance policy designed to pay for your medical aid shortfalls, should you encounter them. Basically, when your medical aid pays only a portion of your hospital or specialist bill, gap insurance covers the difference, helping you avoid large medical bills during an already stressful time.
Gap cover is not a substitute for medical aid, which means you must belong to a registered medical aid scheme to qualify.
Why Medical Aid Members Need Gap Cover
Medical aid schemes often pay at medical scheme rates, which may be lower than the full cost charged by hospitals or doctors. This leaves members with medical shortfalls, co-payments, and out-of-pocket expenses.
Signing up for TRA Gap cover means TRA will, depending on the policy:
- Cover tariff shortfalls for in-hospital procedures and specialist treatments
- Pay co-payments and deductibles
- Cover oncology treatment, breast and dental reconstruction, and private ward upgrades
- Provides accidental death benefits and lifestyle benefits
- Give you access to TRA Assist for additional benefits
Please note that all cover is subject to the annual aggregate limit of R219 845
How Does Gap Cover Insurance Work?
When you receive treatment, your medical aid pays according to your plan’s limits. If there’s a shortfall, your gap cover policy pays the maximum amount specified in your policy terms. Annual limits and waiting periods may apply, so review your cover benefits and policy terms carefully.
Gap cover policyholders must submit a claim form with supporting documents, including medical aid statements, hospital accounts, and receipts. With Total Risk Administrators (TRA), claims are processed quickly, with payments made directly to the insured person or service provider.
What Does Medical Gap Insurance Typically Cover/Include?
- Covers medical aid shortfalls, co-payments, and tariff shortfalls
- Includes benefits for in-hospital procedures, oncology treatment, dental reconstruction, and private ward upgrades
- Offers lifestyle benefits, accidental death cover, and family protection
- Subject to annual limits, waiting periods, and policy terms
- Apply online for fast, convenient cover
Choosing the Right Gap Cover Policy
When selecting the best gap cover insurance, ensure you compare policy benefits, annual limits, waiting periods, and exclusions. Look for all-round coverage, flexible options for family members, and support for medical scheme membership changes.
Providers like TRA (Total Risk Administrators) offer a range of products, with an option for everyone:
- Basic Cover 300, covers up to 300% above medical scheme tariffs, from R99 for individuals and R180 for families
- Vital Cover Plus covers up to 700% above medical scheme tariffs, from R360
- Super Cover Plus covers up to 700% above medical scheme tariffs, from R380
- Absolute Cover Plus covers up to 300% above medical scheme tariffs, from R620
Gap Insurance in Action: A Real-Life Case Study
Ezra, a TRA member, required spinal surgery and faced significant medical expense shortfalls. By choosing our Vital Cover Plus package, Ezra didn’t have to worry after a major in-hospital spinal operation:
| Attending Doctor | Private Rate | Medical Aid Tariff | Gap Cover | Your Share |
| Orthopaedic Surgeon | R 135 269.03 | R 87 464.90 | R 47 804.13 | R 0 |
| Specialist Anaesthesiologist | R 42 516.76 | R 14 343.06 | R 26 765.02 | R 0 |
| Total | R 177 785.79 | R 101 807.96 | R 74 569.15 | R 0 |
Ezra’s medical aid did not cover the full specialist rate, resulting in a shortfall payment due. Gap cover paid the difference, so Ezra paid nothing out of pocket.
Choosing the right gap cover policy can eliminate financial stress after hospital procedures and ensure you’re fully covered for medical aid shortfalls.
Common Questions About Medical Gap Insurance
Is gap cover a substitute for medical aid?
No, gap cover is not a substitute for medical aid. It is supplementary insurance for medical aid members.
What does gap insurance cover?
Gap insurance covers medical aid shortfalls, co-payments, tariff shortfalls, and certain specialist treatments not fully covered by your medical aid plan.
Who can apply for gap cover?
Any member of a registered medical aid scheme can apply online for gap cover insurance.
Are there waiting periods?
Most gap cover policies have general waiting periods and condition-specific waiting periods. TRA does not impose a general waiting period. Review your policy terms for details.
What documents are needed for a claim?
You’ll need your claim form, medical aid statement, hospital account, and proof of payment/doctor’s accounts.
Stick With TRA, The Best Medical Gap Insurance Provider
Total Risk Administrators (TRA) is a licensed non-life insurer and authorised financial services provider, offering competitive gap cover insurance products for medical aid members across South Africa.
TRA helps medical aid members stay fully covered.
Medical gap insurance is a must-have for South Africans with medical aid who want better coverage.
We encourage you to review your health insurance portfolio, looking at your current medical aid and gap cover annually. Make sure your policy benefits, annual limits, and cover options match your needs.
For expert advice or to apply online, contact our team today.
