Do I Need Good Gap Cover?

Medical Gap Cover Insurance is NOT a medical aid or scheme, but rather a short-term insurance that covers you for Gaps incurred with your Medical or Hospital Plan.

Given the spiralling costs of private healthcare and shortfalls in medical aid cover, Gap Cover Insurance has become an essential protection for South Africans and their families. It's designed to cover the often significant 'gap' (or shortfall) between what healthcare professionals charge and what medical aid schemes are prepared to cover.

Note that Gap Cover is not a medical aid or a medical scheme and the cover is also not the same as that of a medical scheme. It is an optional short-term Insurance product designed to help you avoid unexpected shortfalls.

When choosing a Gap Cover Insurance provider, look for a short-term insurance company that is financially stable, has a sizeable customer base and attracts positive reviews.

Some Questions to Consider:
1. Is there cover for procedures conducted out of hospital?
2. What is the overall Gap Cover limit?
3. What is the maximum entry and benefit age?
4. Are there first time cancer benefits?
5. What are the waiting periods?
6. What is excluded from Gap Cover?

Being a specialist niche area, finding a Gap Cover Insurance partner for your family’s requirements is no easy task, because dozens of products are offered by providers in South Africa. These options may be confusing...

In fact, the smartest thing you can do is -- Get a specialist broker to do it for you!

What about Co-Payments, Penalty Fees and Admission Fees?

Depending on your Health Plan you could need more than just Gap Cover. Some gap providers have additional cover for these nasty additional surprises such as co-payments, penalty fees and admission fees.

Co-Payments - The fixed amount excess imposed in terms of your medical scheme rules for undergoing a specific procedure whether in or out of hospital. This will include, for example MRI scans, CT scans, ultrasound scans, and scopes or an elective medical procedure. This will differ from one medical aid scheme to another.

Penalty Fees - The amount you have to pay in terms of your medical scheme rules when you are admitted to a hospital that is not a designated service provider as provided for in your medical scheme rules.

Admission Fee - The fixed amount you have to pay in terms of your medical scheme rules when you are admitted to hospital as an in-patient.

Whilst medical aids are an excellent tool with which to manage your health risk, you may require some additional assistance. Many people choose to opt for medical aid gap cover in order to plan for these possible surprises.

Remember, it is no secret that the provision of basic health services in South Africa is less than adequate. Specialised health services are even more inaccessible to the average citizen plus the lack of structured mechanisms to ensure that funds are spent effectively often result in inadequate quality control, insufficient proper standard risk management and social healthcare programs, which results in the State continually having to manage the healthcare demand with inappropriately used healthcare funding.

This financial responsibility is increasingly being transferred to medical scheme members through the reduction of benefits, limitations to access, and the application of co-payments. Service providers have also become aware of Gap products and in some instances are altering their billing practices to charge more than the rates agreed between themselves and the contracted medical schemes, while specialist health service providers are able to charge any price for their services. This results in a massive burden being placed on the medical scheme member and creates a vast opportunity for alternative health risk models.


Is medical aid gap cover worth it? Unequivocally, the answer is YES. If you have medical aid, you should have Gap Cover to complement it.  Medical procedures are expensive… ... Gap Cover is a relatively inexpensive way to protect you against potentially crippling debt from medical aid shortfalls.

Handy Read: A Basic Guide to Ombudsman Schemes in South Africa

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