How Does Medical Gap Cover Work?

December 16, 2021

How does medical gap cover work? Well, in South Africa, having a medical aid is your ticket to peace of mind. Nobody wants to land up in a state hospital in this country because you don’t have a medical aid. Entry into these hospitals is like signing your death certificate. Even though medical aid schemes are an essential part of life in South Africa, they are so expensive that few can afford them.

Those who can afford them often still have to pay in over and above their premium each month. That’s because some medical costs are far more than what your medical aid is capable of covering and where medical gap cover comes into play. How does medical gap cover work? It covers these amounts that your medical aid can’t cover, and that you would have to pay otherwise.

Who Can Take Out Gap Cover?

How Does Medical Gap Cover Work Zestlife Medical gap cover is for anyone who is a member of a registered medical scheme, and who is 70 years of age or younger. That doesn’t mean when you turn 71 you can’t have gap cover anymore, No, the age limit only applies to new applicants. You have cover as soon as the company receives your first premium and for as long as you pay your policy premiums. Gap Cover is for you, your spouse or life partners and your kids.

Don’t Just Assume

Don’t just assume that once you have gap cover, that you have cover for everything. Gap Cover doesn’t include benefits for PMB claims. There are some cancers which are not covered by Gap Cover. These can be benign tumours, non-invasive tumours, cervical dysplasia and non-melanoma skin covers among a few others. However, gap cover does review each case. There are also GapCover policy exclusions one should consider.

You need to be a member of a medical scheme to qualify for medical gap cover. If you are a medical aid member, please complete and send the form on this page to get a gap cover quote

So How Does Medical Gap Cover Work?

  • Also called medical aid top up scheme, gap cover is for medical costs which you can’t pay out of your pocket.
  • Members of a medical scheme assume that they have complete cover for 100% of costs. Medical schemes in South Africa have different options available. Surgeons etc. get at 100%, 200% or 300% of the scheme rate.  The trouble comes in because specialists in South Africa aren’t  regulated so they can charge more than the 100% rate which medical schemes are willing to pay. The result is that the patient has to pay for the shortfall – money out of their pocket.

How does medical gap cover work?

    1. Only members of medical schemes registered in South Africa may buy medical gap cover.
    2. Gap cover insurance pays the difference between medical aid payments and the actual hospital or specialist bills.
    3. The success of the insurance is its low cost. From R99 per month South African medical aid members can buy gap cover.

More About Gap Cover

  • Gap cover isn’t a medical aid. It isn’t part of your medical scheme membership. Having a Gap policy isn’t part of certain medical schemes. That means you can change your medical scheme, but you keep the same Gap cover. The laws governing medical schemes do not govern gap cover. Your medical scheme is regulated by the Council for Medical Schemes. Gap cover falls under short-term insurance. The process of claiming is also separate from your medical scheme.  Submit your gap cover claim after your medical scheme has paid the service provider.
  • To join, you don’t require a medical examination. You get to cover  immediately.
  • Underwriting applies.
  • Day-to-day services – gap cover does not cover those normal visits to your GP or specialist.

When you ask medical experts, they will advise you to take Gap cover, regardless of the rate your scheme reimburses at.


There is certainly a need for medical gap cover in South Africa. Before you think of downgrading your medical scheme option and taking out more affordable gap cover, speak to a financial advisor. Do not get a shock when next you have large medical costs to pay.

To request a medical gap cover quote, complete and send the form on this page


All info was correct at time of publishing