Why Do You Need To Find Medical Gap Cover in SA?

December 14, 2021

Here we will answer the question as to why you need to find medical gap cover in South Africa.

  • Once you’ve spent everything in your medical aid savings account, the gap cover will still cover GP consultations
  • medical gap cover covers the shortfall between what you have to pay and what the medical aid will pay
  • some gap cover offers a Premium Waiver Benefit. That covers the actual medical scheme contributions following the death of the main member
  • without medical gap cover, you would have to pay some huge medical bills your medical aid won’t
  • medical gap cover prevents you from facing possible bankruptcy


By now, most medical aid members are aware that after years of consultation, Treasury has gazetted final demarcation regulations regarding gap cover, hospital cash plans, and primary health care policies.

Gap cover will continue to exist, but strict regulations came into effect in April 2017.

Most medical aid members realise that medical aid schemes don’t pay for medical treatments in full. South Africans are finding that they are facing more out of pocket medical costs, although they have a medical aid.

The NHRPL doesn’t Exist for most Specialists

Need To Find Medical Gap CoverThe issue is that medical specialists charge rates that are beyond what the medical aid deems as reasonable. They won’t pay for these surplus amounts that are more than what the National Health Reference Price List stipulates.

The Department of Health has drawn up a guide with different codes which suggest the prices for different treatments. Most medical aid schemes will set their scheme tariff at 100% for in-hospital costs, and this 100% by no means suggests everything is paid for.

Mercifully insurance companies have come up with gap cover – a cover that settles those gaps that your medical aid won’t pay and which you will have to. South Africa also has a number of excellent medical gap cover providers.

Some of these, among others, are Stratum, Zestlife, Complimed, and Sanlam. Some of the medical aids of South Africa offer gap cover too. This gap cover isn’t a medical aid, but an insurance-type solution that enhances your medical aid and will help you to avoid those medical payment shortfalls.

Here is why you should choose Sanlam if you need to find medical gap cover.

How much does Sanlam charge for gap cover?

  • Sanlam Gap Cover offers the Comprehensive Gap Cover (younger than 60 years) and Comprehensive Gap cover at a higher price for those 60 years and older.  This includes in-hospital treatment and some out-of-hospital treatment benefits.  Enhanced hospital cash benefits are only available to Sanlam Reality members.

    For more information on the list of additional benefits and exclusions please check out the PDF document at SPF757_Gap Cover_Top Performer May 2018 or read more here 


Why you need to find medical gap cover

There are a number of good reasons to sign up for Sanlam medical gap cover –

  • they offer out-of-hospital treatments for oncology as well as an Emergency Casualty Benefit for accidents
  •  the cover extends to the principal member’s family as well which includes the principal member’s spouse and children up to the age of 26.


Sanlam’s leaders say there will be instances where medical bills will be seriously high. For heart bypass surgery, specialists are quite likely to charge more than 500% of medical scheme rates. In instances like this, the gap cover pay-out amount  will in all likelihood not be enough to take care of the shortfall amount.

If you have to undergo a medical procedure and you have to deal with a payment shortfall, your gap cover will ensure you’re not out of pocket, as long as the procedure has also been covered by your medical scheme up to a certain amount.

Medical aid without gap cover shouldn’t be encouraged as it can leave you bankrupt. Gap cover is simply an essential part of a person’s medical aid cover.

So if you need to find medical gap cover, don’t hesitate to contact Sanlam.

Complete the form on this page to get a FREE gap cover quote

All info was correct at time of publishing