Health Care Gap Insurance Changes

December 14, 2021

Gap insurance changes occur from time to time. Read on to find out the latest.

What are the changes to Gap Health Care Insurance?

  • Gap Insurance payouts ceiling R150 000 per year
  • Primary Health Care benefits are scrapped
  • New regulations became effective 1st April 2017
  • Apply to existing policyholders beginning 2018


After years of consultation with both medical and insurance providers. The Government has implemented regulations to try and better control South Africa’s private healthcare industry.

These regulations will impact on three health care insurance sectors:

  • Gap Cover
  • Primary Health Care Benefits
  • Hospital Cash-Back Plans


How does this affect Gap Cover? – Gap Insurance Changes

Gap Insurance ChangesConsumers with Gap Insurance policies in place before 1st April 2017 will continue to enjoy all benefits until the end of the year.

Then they too will fall under the new regulations.

Consumers who took out Gap Insurance after 1st April 2017 are subject to the new regulations with immediate effect.

What are the new regulations?

The scrapping of primary health care benefits could be a crippling blow to thousands of South Africans, particularly those families in the lower-income group.

Imposing a ceiling of R150 000 per member annually could leave many policyholders out-of-pocket, bearing in mind the exorbitant cost of hospitalisation.

What are Primary Healthcare benefits? – Gap Insurance Changes

These benefits include cover for routine visits to doctors and specialists, as well as dentistry, optometry, pathology, radiology, emergency medical services and acute and chronic medication.

Consumers left stranded

The scrapping of Primary Health Care benefits has left consumers stranded.

So in terms of the Government’s new legislative framework, these benefits must be accredited by the Council for Medical Schemes.

How will the ceiling on Gap Cover affect policyholders?

Ironically, covering the gap for additional expenses involved with hospital treatment is what Gap Insurance is supposed to be all about.

Bills imposed by members of the medical profession are usually in the region of five times more than what medical schemes will pay. Gap Insurance covers the shortfall.

Don’t fall off a ladder!

Somewhat facetious, but nevertheless true, don’t go falling off a ladder now that you don’t have benefits.

The fact is that emergency medical services covered by Primary Health Care benefits are no longer available.

So policyholders will have to fork out additional expenses involved with emergencies out of their own pockets.

What are the changes to Hospital Cash Back Plans?

Changes to benefits on Hospital Cash Back Plans will have a significant financial impact on consumers.

When one considers that the cost of a hospital bed, excluding theatre costs, is in the region of R6 000 daily, the new annual ceiling of R20 000 leaves very little room to manoeuvre.

Conclusion – Gap Insurance Changes

Also, the National Treasury says the reason for introducing new regulations is to try and rein in excessive fees charged by the medical profession.

Critics, on the other hand, have argued that the decision is motivated to stimulate the growth of medical scheme membership which has been stagnant for more than 20 years.


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All info was correct at time of publishing