Gap Cover Plans in South Africa

December 9, 2021

People with a medical aid need to understand how they work. They need to know that if their plan says it will pay up to 100% of your scheme rate, it doesn’t mean it will fully pay your medical bills. Not by a long way. And that’s why insurers invented medical gap cover plans  in South Africa

When choosing a medical aid plan, you will see that some hospitals, clinics and specialists reimburse either 100%, 200%, 300%, 400% and 500% of the scheme rate.  Most people believe that 100% cover means just that – full cover. But is does not, and that’s why insurance companies invented gap cover plans.

Gap Cover Plans in South Africa

You see, there are no regulations governing specialists in South Africa so they can charge patients whatever they want. They can charge far more than the 100% rate which medical schemes are prepared to pay, sometimes as much as 500% or even 600% of the medical aid rate.

The nightmare part comes when the patient ends up with a shortfall and has to find somehow thousands of rands to pay the deficit amount. The answer is medical gap cover plans.

Medical Gap Cover Plans in South Africa

Yes, South Africans are unhappny with their medical schemes. They pay a small fortune in premiums each month and expect the medical aid to cover their bills in full for this. The truth is that medical schemes pay claims at pre-determined scheme rates. That means that when the specialist or hospital charges above this rate, the shortfall becomes the responsibility of the medical aid member.  Most of these surgeons charge well above the recommended scheme rates.

Gap Cover Plans – Some Critically Important Procedures Only Partially Covered

It means that some critical but costly life-and-death procedures are only partially covered by individual schemes. Some medical aid members are outraged when they discover that in fact, they have to pay a bill which is as much as 75% unpaid by the medical aid.  That is why gap cover isn’t a luxury – it has become a critical must-have for every medical aid member.

Gap cover isn’t a part of your medical scheme membership and therefore no laws and regulations apply. Gap cover falls under the Short-term Insurance Act. Fortunately, South Africa has many excellent gap cover providers, some of which are –

  • Medcare Gap Cover  – also extends to certain treatments, medical procedures and co-payments. You get R2 000 000 per family per year. And cover starts from R150 per family per month. You can get this gap cover from Medcare if you are under the age of 65 years.
  • Instant Life – ABSA – a new-generation insurance administrator that offers quality insurance cover and products and all paperless. You and your family enjoy unlimited cover each year. That is important as it fills the gap that results from In-Hospital Medical Practitioner expenses and the amount paid by your medical aid. So for R198 a month you and your family will enjoy an unlimited short-fall benefit.
  • Sirago Underwriting Managers – they are a registered Financial Services Provider offering a variety of financial products tailored for South Africans. You must be under 65 years of age to buy gap cover. They pay the gap cover amount straight into your bank account. Individuals pay R130 each month and a family will pay R140.


Love it or Hate Gap Cover Plans – You Need One

Don’t waste time. You NEED gap cover if you have a medical aid. You can’t buy gap cover without medical aid. Some say medical aids can’t pay the full costs of their member’s treatments, but most people know they just won’t. However you look at it and however unfair you think it all is, you must have gap cover if you don’t want  massive medical bills that your medical aid isn’t going to pay.

If you belong to a medical scheme, just complete and send the form on this page to get a medical gap cover quote

All info was correct at time of publishing