Gap cover: what it is and why you need it

December 14, 2021

Heading into the world of medical aids and health insurance is a big step in any person’s life. And there are a variety of terms and conditions that one needs to familiarise oneself with. That is, if they want to be sure to get exactly what they need from medical aid and health insurance. One specific term that people overlook and which they query when it’s too late is gap cover. We will be looking at all the aspects of gap cover. We will tell you what it is, why you need it, how it works and how you can get it.

Gap cover: what it is

The whole benefit of paying for medical aid is that you get cover for many of your health costs. You may believe that you won’t have to stress about finding money for them. That’s the idea you buy into, anyway. And while, for the most part, medical scheme companies hold to that ideal. However, in certain circumstances, your medical aid may only cover part of the cost of a procedure, treatment or consultation.

This happens when your medical aid coverage relates to a predetermined medical practitioner charge. If the health professional or institutional you visit charge more than your medical aid will pay, you’ll have to pay.

What it is – and is not

Gap Cover What It IsThis “gap” between what the practitioner charges (above the scheme rate) and what your medical scheme covers is where gap cover will save the day.

Why do you need gap cover

Well, isn’t it obvious? You need gap cover to provide coverage for the extra costs your medical aid won’t refund you for. Let’s say you are in an accident, go for scans and land in hospital for a couple of days. And let’s say that by day two your medical aid stops covering. Well, then you’re in for a mountain of medical accounts. And you will have to settle them yourself.

That money will need to come from somewhere. And, unless you’ve been saving specifically for this moment, you won’t be able to afford it. And that’s why you need gap cover.



What it is: The way gap cover works

Depending on who you buy gap cover from, the insurer will either cover the entire co-payment. Or they will pay a bulk portion of it based on what your medical aid is covering. So, for example, some insurance companies will choose to payout either double or even up to five times of what your medical scheme is paying.

In these circumstances, you may still be left with a percentage of the co-payment to be paid from your own account. However, it will be substantially less than what it would have been without gap cover. You will, at least, be able to afford your medical bill and not be left in too much debt, if any.

There are also certain things that gap cover will and won’t cover and you need to make sure you’re aware of these when you decide on a gap cover provider. Here are a few examples of what the majority of gap cover insurers will cover (please note, not all insurers have the same gap cover schemes or coverage options):

  • Certain hospital procedures (co-payment).
  • Long-term hospitalisation (lump sum).
  • Cancer diagnosis and treatment (contribution).


As for things that many gap cover policies don’t cover, those include waiting period procedures, cosmetic procedures, private nursing or room upgrades and medication. Again, not every insurance company will have the same benefits and limitations to their policies and you should consult with your broker in these cases.

What it is: How do you get gap cover

It’s been established that you (and your bank account) could do with gap cover insurance on top of your medical aid scheme. And while you may think it counterintuitive to pay more every month for merely the possibility of an emergency situation, when that situation occurs, at least you will be prepared. And it’s always better to be prepared, in this case covered, as it will undoubtedly cost you less in the long run.

So, how do you get gap cover? You’ll need to pay a visit to a health insurance company and see what they have to offer in the range of gap cover policies. African Unity Insurance, for example, has an African Unity Health (AUH) Gap range and a Care Gap range of gap cover products that you can choose from to suit your coverage needs. Under these ranges, you’ll find an extensive breakdown of what is and is not covered by AUH and what the different pricing options are for the different coverage products.

If you’ve gone through the trouble of getting medical aid, you may as well do it properly and take out gap cover as well. It makes the most financial sense and it will make all the difference, should it be put to use.


Please complete the form on this page and then “click to send” the form. We will return to you with a personal quote so you can sign up for gap cover. Remember: only members of registered medical aid schemes can sign up for gap cover


All info was correct at time of publishing