Gap Cover for a Hospital Plan

December 19, 2021

What is gap cover for a hospital plan?

  • It is insurance to ensure you don’t pay out of pocket for in-hospital expenses.
  • Not all expenses will be covered by your medical aid.
  • It is an added insurance that is separate from your medical aid.
  • You must have a medical aid or insurance to qualify.
  • The pay-out is based on the shortfall not paid by your medical aid.


It is commonly assumed that when you are in hospital for any reason, your medical aid is going to pay for everything. The truth is that this is not always going to be true. In most instances, the medical aid is only going to pay a portion of the fees that the hospital charges.

For full cover, therefore, you need something extra. Gap cover for a hospital plan or full medical aid (which ever you have from a medical scheme) is where that extra comes into play. What you need to realize first is what gap cover is not. It is NOT a medical aid and it is not a cash back plan.

So, What is Gap Cover Then?

What it is, is cover for the gap between what you are charged by the hospital, doctors, etc. for a procedure in hospital and what the medical aid pays out. The gap cover will normally pay this difference to you but it is left up to you to pay the bills with it.

Why Get Gap Cover for a Hospital Plan?

Gap Cover for a Hospital PlanSouth Africans have a lot to choose from when it comes to medical aid and insurance. Most medical aids offer to provide cover of at least 100%, some 200% or more. This sounds good until you realize that the cover depends on the medical scheme tariffs.

And that medical scheme tariffs might be a lot lower than what your hospital stay actually costs you. It’s all in the fine print on this one, and, in this case, this could cost you a lot of money. And don’t get upset with the medical aid – it isn’t trying to deliberately pull the wool over your eyes.

How Are Medical Aid Tariffs Determined?

It’s just that the medical aids have a responsibility to all the members in the scheme. Strictly speaking, they are supposed to take all the contributions by all the members and use those to pay out the member’s claims. They have to put some form of limit on claims so that the members all see some sort of benefit.

Unfortunately, this means that they take a look at the average cost paid out per procedure in the previous year and then look at how much they expect to get in revenue for the upcoming year. This helps them to determine the maximum they will pay out for each upcoming claim.

The doctors and other health care professionals get to set their own rates and don’t have to stick to these predetermined rates at all. And sometimes, they charge well in excess of what the medical aid will pay.

Who Qualifies?

This is a specialized medical cover, only members of a registered South African medical aid qualify. Not all cash back plans and medical insurances fall under this banner. It’s therefore important to check upfront whether or not you do qualify.

In fact, it’s a good idea to your research when choosing a medical scheme in the first place – what is a hospital stay going to end up costing you if you don’t qualify for gap insurance?

Next step: complete and submit the form on this page to get a personal gap cover quote


All info was correct at time of publishing