Medical Gap Cover in South Africa

December 8, 2021

Does your medical aid savings last the whole year? Have you ever got a massive bill to settle personally, after a stay in a hospital? And this when you thought your medical aid was going to pay 100%? If not, you should consider signing up for medical gap cover in South Africa.

Instead of a stint in hospital being a time of restoration, the bills you face could keep you there longer because of the stress. If you don’t have the means to settle your various hospital bills, how are you going to manage the amount your medical aid doesn’t cover? Take out yet another loan and go deeper into debt?

Although many South Africans are members of medical aids, they still find themselves paying hefty ‘out-of-your-own-pocket’ costs for medical care each year.


What is Medical Gap Cover in South Africa

  • Gap cover is a short-fall insurance that works independently of your regular medical aid.
  • It pays out the difference between what your medical aid pays, and the rates your healthcare professionals may charge.
  • Medical aid rates work according to your medical aid, guided by the NHRPL (National Health Reference Pricing List) So when the fine print in your medical aid contract says they will pay 100% of medical aid rates, it means that they will pay in full according to the rate determined by them toMedical Gap Cover in South Africabe a fair one.
  • However, the specialists that you saw in the hospital don’t have to comply with any of these rules, and may charge whatever they want.
  • That means that your specialist, anaesthetist, radiology and pathology departments may charge up to 500% more than the amount settled by your Medical Aid.
  • Hence the huge shortfall, for which you now have to fork out.Gap Cover is a short-term insurance available only from a registered Financial Services Provider.


Features of Medical Gap Cover in South Africa

  • You need to belong to a registered medical scheme.
  • Besides the principle member, all members of the family can be beneficiaries of the gap cover.
  • Waiting periods: there is a general waiting period of 3 months. For any pre-existing medical conditions, the waiting period is generally 12 months.
  • Insurance companies do not settle claims older than 6 months. Usuallya the gap company gets the claims after the medical aid has paid their portion.
  • Some gap cover service providers have annual limits on certai n conditions, such as the treatment for cancer.
  • Monthly premiums start from as little as R250 per month, but generally speaking you get what you pay for. This means that people paying R600 per month will be receiving a more comprehensive cover.
  • Depending on your cover, co-payments on hospital admissions, the gap company will pay for CT scans and MRI scans.
  • Cover available for specialised dentistry after an accident, and cancer treatments .
  • Treatment in the emergency room after an accident will also be covered, even if you are not admitted to hospital.
  • Some gap cover service providers won’t allow over 60’s to take out cover, but others have no maximum age limits.


Examples of Shortfalls after the Medical Aid has paid – for your own pocket

  • Appendectomy – R2 053.26
  • Caesarian Section – R8 413.76
  • Coronary Bypass – R27 164.20

Unless you are prepared to pay an extra amount for a stay in hospital, it would be wise to consider Gap Cover. Otherwise an unexpected hospital stay could be financially crippling to you and your family.

To get a FREE medical gap cover quote, please complete and send the form on this page. Just type and click to get a quote.


All info was correct at time of publishing