Medical Aid Gap Cover Makes up the Shortfall that Private Hospitals Charge

December 9, 2021

Medical aid gap cover is being looked at with renewed interest by scheme members in South Africa.

The reason for this is that the National Health Reference Price List  (NHRPL), which is a pricing system, dictates the rates medical aid have to pay.

Medical aid companies, according to law, have to pay up according to these rates, but hospitals and doctors do not have to stick to these prices. A gap emerges, making shortfall cover necessary.

What is  Medical Aid Gap Cover Actually and How Does it Work?

Medical Aid Gap Cover in South AfricaPrivate hospitals and many specialists take advantage of this anomaly. They can charge just what they like – as much as 300% above NHRPL prices. That is why so many South Africans are sick of their membership.

They believe they have covered adequately for all medical treatment, specialists and eventualities when in fact they aren’t. They have to then find money to make up a shortfall that occurs when the final bill arrives. That’s where medical aid gap cover comes into the picture

Gap cover is available to anyone who is a member of a medical scheme it helps cover all those medical costs as well as hospitalisation costs that your medical aid won’t pay out when you put in a claim.

Gap cover ensures you are never out-of-pocket. In short Gap cover is short term insurance that covers the gap between what your medical aid pays and what private hospitals and medical doctors charge.

Universal Gap Cover from Zestlife

Here are Zestlife’s 2019 enhancements:

  • Overall regulatory maximum for medical expense shortfall cover increased from R150 000 to R160 000.
  • Cancer lump sum increased from R25 000 to R30 000.
  • Casualty benefit increased from R10 000 to R20 000. Casualty visit must be within 48 hours of the accident.
  • Medical Aid and Gap Cover Premium Waiver maximum increased from R6 500 toR7 300.
  • Medical Aid and Gap Cover Premium Waiver limited to accidental only, but the payment period increased from 3 to 12 months. This change was due to legal requirements.
  • Accidental dentistry maximum increased from R15 750 to R19 250 and amount per tooth increased from R2 250 to R2 750.
  • Non-Designated Service Provider co-payment increased from R8 600 to R9 300.
  • Oncology co-payment maximum increased from 20% to 25%.
  • Cover for robotic procedures up to R30 000.
  • Cover for procedures in day clinics.
  • New Oncology Benefit to cover 20% of treatment cost when oncology limit is exceeded.
  • Varicose veins have been added as an out-of-hospital procedure that is covered.


Zestlife Premiums for 2024

Zestlife Gap Cover 2024




  • Is there a waiting period with Gap Cover?
    The waiting times clauses will depend on the insurer – anything from no waiting period to  3 months from inception date.
  • Is there Excess on Benefits?
    For those members older than 60, some products will have an excess payable on benefits


Registered scheme members are reluctantly aware that they have to fork out additional premiums for medical gap cover.

Add to this the fact that the Council for Medical Schemes has announced that they will deplete the pool of funds for the various options, making medical gap cover regarded as a very necessary evil for medical aid members.

Medical aid members can apply for one FREE shortfall quotation
by completing and sending the form on this page

All info was correct at time of publishing