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

    February 8, 2019

    Despite the ever-increasing cost of medical aid, more and more South Africans are augmenting their healthcare plans with gap cover. Gap insurance makes up the shortfall between real bills and what your medical aid covers.

    Makes up the shortfall between


    Basically, gap cover is a short-term insurance policy not unlike a top-up insurance offered by the motor industry. It pays in the difference between what a medical scheme stipulates in their prescribed tariff–rate index and what members of the medical profession charge for their services.

    In fact, the ever-widening difference between medical scheme rates and private medical practice fees has been the driving reason why consumers, albeit reluctantly, have had to accept gap cover as a must-have added insurance benefit.

    Medical schemes have to abide by the National Health Reference Price List  (NHRPL) which dictates tariff rates, while medical practitioners and private hospitals, who are not regulated by any government agency, are free to charge what they like. And that difference can sometimes be a staggering 600% more than what a medical aid member receives from the scheme and what h/she is actually billed by members of the private practice.

    This has resulted in gap cover no longer being an added extra luxury but rather as an absolute necessity to safeguard against healthcare costs over-and-above what consumers can afford to pay. Gap Cover is an affordable necessity and is available to all registered members of a recognised South African medical aid scheme.

    Here we take a look at two of the options available:

    Essential Gap Cover by Liberty Health Makes up the Shortfall

    Policyholders are covered for up to R150 000 per person annually and benefits include:

    • In-hospital cover of up to three times more than the medical scheme tariff
    • Out-of-hospital cover of up to three times more than the medical scheme tariff
    • Co-payments for hospital admissions, scans and prescribed surgical procedures
    • Emergency coverof up to R20 000 annually for accidental injury

    Essential Gap Cover costs a family below the ages of 65 years, R344 a month. Senior citizens are catered for at a monthly cost of R393.

    Sanlam Gap Cover Makes up the Shortfall

    Sanlam offers gap cover for R298 a month for people younger than 60 years and benefits include:

    • In-hospital tariff shortfalls for up to five times the amount covered by the medical scheme
    • Sub-limits for procedures such as prosthetics for up to R48 500 per event
    • Co-payments – unlimited cover for specified procedures
    • Out-of-hospital benefits including scans (unlimited) and oncology benefits amounting to R157 000 per person annually
    • Emergency benefits amounting to R14 000 per event and limited to one event per year

    Sanlam offers gap cover to people over the age of 60 years at a monthly premium of R700.

    One-stop-shopping

    Before deciding on a gap cover service provider, consumers are urged to investigate all the options available and they can achieve this with one platform. Visit the hippo.co.za website, enter your details and requirements, and you will receive comparisons of products and prices to suit your individual needs and budget restraints.

    Other relevant information about gap cover includes waiting periodbenefits. This can vary between service providers but while some offer instant cover from the moment the first premium is paid, most insurers have a three-month waiting period clause.

    If you are a member of a medical scheme then you are entitled to a gap cover quote when completing the information required on the form displayed on this page.

    Complete and submit the form on this page to get your complimentary gap cover quote now!

    All info was correct at time of publishing