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

    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 which 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 now strict regulations have been enforced since April 2017. Gap cover policies are now limited to a payout of R150 000 per annum per client.

    Most medical aid members are also wise to the fact 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.

    This is a list drawn up by the Department of Health as 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?

      • Sanlam offers 2 products – Comprehensive Gap Cover and Standard Gap Cover
      • Sanlam Comprehensive is R198 per family per month. However, for those over 60 years of age, it is R400 per family per month
      • the maximum entry age for these plans is 59 years.
      • with the Standard Gap plan, the premium for individual and family is R166 per month
      • for both plans tariff shortfalls are up to 500% of scheme tariff


    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 up to R9 500 per event.
    •  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 of R150 000 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