How Does Gap Cover Work?

December 14, 2021

Gap Cover is an additional product to your medical. Only people with a medical aid can get gap cover. Gap cover is offered by medical aids and by independent third parties. So how does gap cover work?

Gap cover comes into play when your medical aid is not willing to pay the full account for hospital bills. The gap cover provider will then pay the remainder of the account up to a certain percentage. Gap cover is specific to treatment in-hospital, although some gap cover providers will add extra benefits.

Insured persons

Gap cover insures the main member and his/ her dependents that are registered on medical aid. Newborn children can also be insured if the baby is registered within 30 days from birth.

You will need to register each person for the gap cover. Some providers place a maximum age limit on certain gap cover options.

Coverage – How Does Gap Cover Work

How Does Gap Cover WorkGap cover is specific to in-hospital claims. However, many gap cover options now cover other items. Co-payments for hospital stays, cancer treatments and drugs, and incidents relating to an approved admission may be covered by your gap cover.

Gap cover will not pay for day-to-day doctor visits or general medications. Some gap cover products will pay for certain out-patient treatments. You need to read your policy to understand the coverage.


Treatment for pre-existing medical conditions will be excluded from most gap cover options for 12 months. Certain other exclusions may also apply and these will vary between three and 12 months. Birth-related costs are often excluded for a certain period of time. You need to clearly check this with your gap cover provider.

Claims – How Does Gap Cover Work

When you are in the hospital you may get a bill for an amount that the medical aid does not pay. You can then send that account to the gap cover provider. The claim will be assessed and the gap cover provider will then pay the required amount to you or the hospital.

Most gap cover providers require you to submit all the accounts within a set time period in order to pay the claim. You may also be asked to submit additional documents.

Costs and limits

Gap cover is an affordable insurance product with some options being under R100 per family per month. The more expensive options will offer full coverage and added benefits.

The gap cover is usually limited to a set amount per year. This is the maximum amount that the gap cover provider will pay for claims.

Besides an overall limit, there will also be limits for specific treatments, admissions, or procedures. These limits are usually provided as a limit per person and per family.

Gap cover is the backup plan for when your medical aid is not enough. Emergencies and unexpected medical costs can happen at any time and to anybody. Getting gap cover is a safety net for when you or your family are hospitalised or have a long-term illness.

The benefits of gap cover far outweigh the costs.


Complete and submit the form on this page to get a gap cover quote. 

All info was correct at time of publishing