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

    September 17, 2015

    Medical aid gap cover is being looked at with renewed interest by Medical Aid 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 medical aid gap cover necessary.

    Medical aid members can apply for one FREE medical gap cover quote
    by completing and sending the form on this page.

    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 medical aid plan cover.

    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.

    Essential Gap Cover offers two medical aid gap cover policy options –

    • Elite –  requires just R140 per month and covers up to 500% and with an annual limit of R250 000.
    • Prestige membership – includes 600% of the gap and at R160 per month.


    From a mere R125 each month, Sanlam medical aid gap cover Insurance will take care of the difference between what the medical scheme pays and the rates charged by medical specialists.

    These are just two examples of medical aid gap cover. How do you know where to look for the best medical scheme gap cover in SA? finds quotes and makes all the comparisons for you. It compares providers such as Sanlam and Essential Gap for instance along with other service providers, saving you all the bother and inconvenience of shopping around for quotes.

    There are some medical aid schemes which have adjusted their rules and benefits impacting the amount members will now need to pay for the shortfalls, and where once they covered members up to 300% of medical aid tariff, they now only pay 200% of medical aid tariff.

    Two other questions that Hippo will, for example, answer about Medical Aid Gap Cover are –

    • 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


    Medical aid 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 medical scheme plans, making medical gap cover regarded as a very necessary evil for medical aid members.

    Medical aid members can apply for one FREE medical gap cover quote
    by completing and sending the form on this page

    All info was correct at time of publishing