Do I Need Gap Insurance for Medical Aid?

December 16, 2021

The answer to the question, “Do I need gap insurance?” is an emphatic yesif you want to avoid the possibility of a financial disaster that could leave you and your family bankrupt.

Never, for one minute believe that you are fully covered for all your healthcare requirements because you are a member of a medical aid scheme. If you take the time to examine your medical aid contract you will quickly discover that there is a myriad of shortcomings that will leave you with additional and, most often, unexpected financial outlays.

That’s where gap cover comes into play. It is a short-term top-up insurance policy that covers you for the financial shortfalls between what your medical scheme will pay and what you are billed by the medical profession. These differences can amount to thousands of Rand and, without gap cover, could leave you in dire financial straits.

Do I need medical gap cover

Here we answer some of the FAQs relating to gap cover.

Why do I Need Gap Insurance?

Every member of a medical aid scheme should supplement their healthcare portfolio with gap cover to ensure that they will not be personally held liable to pay in the difference between medical scheme tariff rates and medical profession costs.

How do medical practitioners arrive at their service fees?

The medical profession is not regulated by the government and is entitled to impose whatever fees they feel fit for their services. This applies to all medical professionals such as surgeons, anaesthetists and radiologists. It has now become common practice for members of the medical profession to charge five times more than the prescribed tariff rates applied by medical schemes. Without gap cover, you will be held personally liable to fork out the difference.

Can you give me an example of the differences in these fees?

Caesarean births at a private hospital will cost upwards of R26 000 and exclude fees imposed by gynaecologists, anaesthetists and paediatricians which can add another +R20 000 to your bill. These costs are based on deliveries with no complications but emergency caesareans will skyrocket the final cost of bringing your child into the world. Medical scheme tariff rates may vary but one thing is for sure, they will never cover the full costs involved with giving birth.

Depending on the level of benefits of your medical scheme, their final pay-out compared to the bills from a private hospital and medical professionals could leave you with a financial shortfall large enough to leave you with sleepless nights. Gap cover will pay in that difference, saving you a chunk of cash that you can invest in your child’s future.


With no gap cover, you are left in a sink-or-swim situation. No member of a medical scheme can afford to ignore the importance of supplementing their healthcare portfolio with this very necessary form of short-term insurance because, without it, you will most definitely sink.

To obtain a medical gap insurance quote, please complete the form on this page.

All info was correct at time of publishing