About Ambledown Medical Shortfall Cover

December 18, 2021

Many members of Private Medical Schemes have a rude awakening when the cost of hospital procedures is not fully covered. Here we will have a look at Ambledown medical shortfall insurance.

Medical schemes have set tariff ceilings and when medical practitioners impose higher fees members are left with shortfalls. These unexpected out-of-pocket expenses can be crippling.

Ambledown Medical Shortfall Insurance

That’s when Ambledown’s Gap Series insurance can prove to be a financial life-saver – filling the shortfall between medical aid tariff limits and the medical profession’s final bill. It covers the principal member of the insurance policy, as well as all listed family dependents.

Ambledown Medical Shortfall InsuranceIt covers the Gap between charges levied by medical practitioners and the Medical Scheme Tariff (MST) for hospital procedures, as well as for out-patient treatments for cancer patients in need of chemotherapy or radiotherapy and for kidney dialysis.

In fact, Ambledown’s Gap Series offers a generous annual limit of R2 million and will pay up to five times more than the MST limits.

The cover excludes hospital fees or additional costs for prosthesis, medication and materials, but includes services given by medical professionals, including physiotherapists, during in-hospital procedures.

Apart from this, Ambledown will pay up to R100 000 per family annually for co-payments revolving around out-patient treatments for MRI and CT Scans. Medical schemes charge co-payments when medical practitioners require up-front payments for various procedures. Members must obtain authorization from the company and use a recognised network hospital to qualify for this benefit.

Furthermore, Ambledown pays a maximum of R50 000 per family annually for sub-limitation cover – the Gap between medical scheme ceilings and medical profession charges for in-hospital admissions.

Cancer Patients

Cancer patients receive up to R500 000 per treatment cycle and have cover for co-payments and deductibles. As well as sub-limitations by medical schemes for biological cancer drugs. It also covers specific sub-groups of cancer.

The cover includes in-hospital expenses, chemicals and medication, as well as radiotherapy and chemotherapy received as an outpatient. It does, however, exclude consultations with specialists.

Casualty Benefit

The Casualty Benefit covers *emergency medical treatment in a hospital casualty unit. If not covered by a medical scheme, a member can receive up to R10 000 per family annually for costs involved with admission to a hospital casualty unit.

(*Emergency is defined as the sudden and unexpected onset of a health condition that requires immediate medical attention).

Premium Waiver Benefit: In the event of death or permanent disability of a principal member, Ambledown will pay his/her medical scheme premiums for six months.

GAP Listed Procedure Enhancer – Ambledown Medical Shortfall Insurance

GAP Listed Procedure Enhancer covers the following:

  • In-hospital dentistry involving reconstructive plastic surgery necessitated by accidents and impacted teeth for minors under the age of 18
  • Functional nasal surgery
  • Oesophageal reflux and hiatus hernia surgeries
  • Treatments or surgeries for back and neck conditions
  • Joint replacements, including but not limited to hips, shoulders, knees and elbows
  • Procedures, devices and processors for cochlear and auditory brain implants and internal nerve stimulators
  • Bunionectomy
  • Arthroscopy
  • Varicose vein removals
  • Skin disorders such as benign growth and lipomas


This GAP 100 benefit pays out up to five times the Medical Scheme Tariff and limits to R2 million per family annually.


Complete the form on this page to get a FREE gap cover quote.

All info was correct at time of publishing