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What Is Medical Gap Insurance and What Does It Cover

What Is Medical Gap Insurance & What Does It Cover

Trying to navigate the intricacies of the healthcare system can be a tall ask, especially when considering the unexpected medical expenses that can get involved. While the traditional route of just taking out a medical aid plan can provide the most essential coverage, individuals with more substantial out-of-pocket costs can be left on the sidelines when they need help most. As a means of bridging this gap, many people opt for the extra coverage that gap cover has to offer. With greater financial protection, many people are turning to medical gap cover to ensure their health and that of their loved ones is covered from every angle.

With a clearer understanding of this valuable form of supplementary coverage, more people can grasp the fundamentals of medical gap insurance, explore its key features and benefits, and examine the types of expenses it typically covers for them. TRA is here to help you explore the concept of gap cover, truly understand how it works alongside medical aid, and delve into what it covers.

So, let’s dive into the world of medical gap insurance and discover how it can offer a safety net against the escalating costs of healthcare.

What Is Medical Gap Cover?

gap cover policy is a short-term insurance product designed to work hand-in-hand with your medical aid to provide extra cover and financial protection to those already utilising medical aid. Gap cover can cover the shortfall cost between your medical scheme tariff and the rates charged by private healthcare providers.

Gap cover is applied to cover all or part of the difference between the amount your medical scheme agrees to pay and the full rates charged by the medical practitioner or facility. Depending on which policy type you choose, the cover will differ from policy to policy. Accordingly, gap cover plans are not stand-alone insurance policies but are group supplemental health plans intended to augment your existing cover.

In addition to covering routine medical consultations and procedures, gap cover can make up the shortfall of payments for treatments related to several critical illnesses, including cancer, renal problems, strokes, comas and heart attacks.

Types of Medical Gap Cover

Total Risk Administrators offers four different types of medical gap cover. They are as follows:

Basic Cover 300

The basic plan provides gap cover for casualty visits and provides up to R3000 in cover when the insured suffers from accidental death. Starting at R99 per month, this plan additionally covers oncology diagnostics and treatments. It also includes the TRA Assist facility, which provides a Home Drive service (including access to free Uber trips), a Panic Button and a Medical Health & Trauma counselling line.

Vital Cover Plus

In addition to the cover provided on the Basic Cover 300 plan, Vital Cover Plus also includes a Sub-Limit cover on internal prostheses. Coming in at R220 per month for those under 65s, this plan also offers up to R10 000 per policy per annum on co-payments.

Super Cover Plus

For an additional R30 per month, the Super Cover Plus policy includes the benefits of the Vital Cover Plus plan and a Global Fee Benefit. Where a global fee has been negotiated between a medical aid and service providers for a specific procedure. The service providers then charge in excess of that amount, so the policy in place will cover the additional amount.

Absolute Cover Plus

Our flagship gap cover product offers full gap cover, casualty cover, co-payment cover and sub-limit cover. This policy option also covers augmented oncology cover, including gap cover, co-payment cover, and an extender plan. This policy costs R450 per month for those under 65’s.

The Benefits of Medical Gap Insurance Cover

It is not unusual for medical expenses to exceed medical scheme benefits, leaving people having to use savings or credit facilities to cover costs. Medical gap policies help reduce exposure to these debts and enable you to cover your expenses without having to borrow or use the cash you had set aside for other purposes.

Gap insurance cover pays some, or possibly all, of the gap between your medical scheme’s payment and the fee demanded by medical practitioners. Total Risk Administrator’s gap cover consists of several benefits that can be applied to various medical expenses.

  • Basic Gap Cover helps you avoid out-of-pocket expenses for various medical treatments.
  • Casualty Cover makes sure that you are prepared for unexpected visits to hospital casualty wards.
  • Oncology Gap Cover is designed for diagnostics and treatment in cancer cases
  • Co-payment Cover gives you peace of mind regarding co-payments and deductibles.
  • Sub-Limit Cover is there to assist when medical schemes impose sub-limits on in-hospital prostheses or limit the monetary amount that is available for MRI, CT and PET scans.
  • Global Fee Benefit comes into effect when medical facilities charge more than the agreed global fee on a specific procedure.
  • Oncology Extender Benefit includes any approved costs above an annual scheme oncology limit, subject to the scheme covering costs up to that limit.

Medical Gap Insurance Plan Requirements

To qualify for medical gap cover, you must be an existing medical aid scheme member. If you have an existing medical condition, you can still qualify to take out the gap cover policy. However, it must be noted that no claims relating to certain pre-existing conditions will be covered within the first ten months of membership. This includes cover for pregnancy.

If you have any of the stipulated pre-existing conditions, you are still welcome to join the scheme, but you will not be able to claim in relation to those conditions until the waiting period is over. After this waiting period, claims in relation to these conditions will be considered. There is no entry age limit, although premiums are higher for clients who are 65 and older.

Total Risk Administrators will provide gap cover for you, regardless of what medical scheme you are already on (as long as it is registered with the CMS). The gap cover will provide benefits for members and their dependants (spouse and/ or child/children up to the age of 25 years only ) who are covered on one policy of a registered medical aid scheme.

Members and their dependents can only be on two different medical aids and one gap cover policy if they are legally married or common-law partners. This would need to be verified by submission of an affidavit confirming 12 months of cohabitation. It must also be noted that the provision of gap cover is subject to an aggregate annual limit of R165 000 per insured person per annum.

What Most Medical Gap Policies Do and Do Not Cover

It’s important to remember the limits of gap cover. There are several things that Total Risk Administrators’ policies will not cover. These include but are not limited to:

Ward costs in a hospital

Upgrades to a private room

Pre-admission consultation costs


External prostheses

Wheelchairs or crutches

Routine medical examinations

Home or private nursing

Extra costs related to weight or BMI-related procedures

Mental health disorders

Transportation costs

Out-of-hospital dental treatments

Cosmetic procedures

Costs incurred for treatment by a non-designated service provider

Co-payments for any procedure for which you are in a waiting period

It is also important to note that gap cover schemes will only pay the shortfall on claims that your medical aid has already partially paid. Where your medical aid does not cover any portion of the account, you cannot claim from your gap cover. For procedures such as paid MRI, CT and PET scans, medical aids sometimes reject claims, and gap cover cannot help in these instances.

If you have to visit an emergency room for any reason and have a medical aid scheme with a Medical Savings Account, you can generally claim the costs from your savings. Medical gap plans will usually only cover these types of claims for accidents or for children under the age of eight, subject to certain other conditions.

Medical Gap Insurance Waiting Periods

Most medical gap policies apply waiting periods for various pre-existing conditions. During these waiting periods, the insured individuals are not able to claim from the plan. With Total Risk Administrators, there is no general three-month waiting period. However, there is a ten-month waiting period for a variety of conditions, including the following:

Head, neck and spinal procedures

Endoscopic procedures

Pregnancy and childbirth

Gynaecological conditions

Joint replacement

Inability to walk or move without pain

Any renal or bladder conditions

Cardiac conditions


Cataracts or eye laser surgery

Neurological conditions and procedures

Organ transplants

Reconstructive surgery as a result of an incident or condition that occurred before membership

Mental health or psychiatric conditions

Varicose veins

Oesophagitis, gastroenteritis

Male genital system problems

Carpal tunnel syndrome

Ear, nose and throat procedures


If a Policyholder is diagnosed with any form of cancer prior to membership, all related claims will be subject to a nine-month waiting period. If a Policyholder has previously been diagnosed with cancer and is currently in remission, the Policyholder needs to advise the insurer through medical evidence that the remission period has been for two or more consecutive years.

No claims relating to any pre-existing conditions that may lead to hospitalisation (excluding cancer: see above) will be covered within the first six months of membership. The insurer reserves the right to request any clinical information from a Policyholder’s doctor should a claim indicate or relate to a pre-existing condition in this period.

All claims for these conditions received within the waiting period will be reviewed by medical management to identify pre-existing conditions.

How To Choose The Best Medical Gap Policy

Before signing up for a medical gap cover plan, the best thing to do is to pursue the policy very closely. Firstly, check what is covered and not covered in the policy. Also, consider whether it will meet all your needs and if there are any exclusions that will not suit you.

Then, check if there are any conditions relating to the age of the insured. Some policies will stipulate different premiums for different age groups. Make sure that the premiums are affordable and reasonable for your specific age group.

Next, see what the policy’s waiting periods are, as some gap cover plans impose a general three-month waiting period for all new members. Total Risk Administrators does not impose this waiting period. There are waiting periods relating to specific conditions, as discussed above. If you or any family members have any of the stated requirements, you will not be able to claim until the stipulated waiting periods have passed.

Having read through all of the terms and conditions, look for reviews of the gap cover provider on Hello Peter and similar review platforms. If the reviews are mostly good, you can maybe trust the scheme. Don’t just look at star ratings; read the reviews thoroughly and see what people say about the insurer. This includes their service, any claims issues and so on.

The first few reviews on a site, together with the aggregate star rating, will give you a good idea of what to expect from the provider. However, negative reviews aren’t everything- and if there have been negative reviews, ensure to check whether the review was responded to timeously and efficiently, which is also a good sign.

Lastly, weigh up the premiums against the expected benefits, and make a judgement call on whether it seems a worthy exchange.

FAQs: Medical Gap Policies

Is a medical gap policy tax deductible?

Unlike the contributions you make to your medical aid scheme, gap cover cannot be claimed as a tax credit. You can, however, include your gap cover contributions under ‘not paid by medical aid’ on your tax return.

What are the maximum benefits?

Total Risk Administrators provides a maximum aggregate benefit of R165 000 per insured person annually.

What Does GAP Stand For?

‘Gap’ is not an acronym in this instance. It refers to the actual gap or shortfall between the rates charged by medical facilities and the amount a medical scheme is prepared to pay.

How long is medical gap insurance valid for?

There is no time limit on the validity of gap cover. As long as you are paying your premiums, your policy is active and valid. There is also no maximum expiry age.

Is it worth purchasing supplemental health insurance?

Considering the fact that medical aid schemes consistently fall short of the total fees demanded by medical service providers, it is most definitely worth having gap cover. For a small monthly premium, you can increase both your cover and that of your family for medical expenses. This is much better than having to find money to deal with unexpected costs.

Will the medical gap cover pay for my consultation with the doctor?

No, gap cover will not pay for routine GP consultations or pre-or post-operative check-ups.

Can I get one month’s gap medical cover?

No. You need to take gap cover on an ongoing basis over an extended period.

Does a medical gap policy pay a lump sum?

No. Medical gap cover will only pay specific amounts for medical scheme payment shortfalls on specific medical services. However, some of the additional benefits on the policy may offer lump sum payouts.

How do I get gap health insurance?

Contact Total Risk Administrators or fill in our online application form.

Your Provider Of Choice

Gaining popularity in recent years, gap cover helps individuals that are seeking comprehensive protection against exorbitant healthcare bills. Offering major assistance, gap cover steps in as a product that holds significance in the world of medical insurance.

Total Risk Administrators aims to empower clients to make informed decisions about their healthcare needs and choose the best option for them. As a proud provider of a variety of cover products, we specialise in funeral cover, female cancer cover and medical gap insurance. Explore our website to learn more, or contact us for more information on any questions you might have.

Note: All material on this website is provided for your information only and may not be construed as medical advice or instruction. No action or inaction should be taken based solely on the contents of this information; instead, readers should consult appropriate health professionals on and matter relating to their health and well-being. The information and opinions expressed here are believed to be accurate, based on the best judgement available to the authors, and readers who fail to consult with appropriate health authorities assume the risk of any injuries. Errors and Omissions Excepted. Terms and Conditions Apply.


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