Payment of Gap Cover Premiums Explained

December 11, 2021

If you belong to a medical scheme in South Africa, you need gap cover too. Here we explain what gap cover is, why you need it and how the payment of premiums works.

What is gap cover?

Medical scheme members will be familiar with co-payments. These are the amounts that medical aids will not pay for various hospital procedures, specialist consultation and medication.

These are the large amounts that medical aid members have to pay out of their own pockets.

South African medical scheme members have lost their homes and their savings due to co-payments. Gap insurance (also called top-up insurance or shortfall cover) takes care of this problem.

You gap insurance pays the co-payments amounts so you don’t have to.

Why you need gap cover

Take a close look at your medical aid contract. Does it say you have 100% cover? Maybe it says you have 200% cover. Or 300% cover?

Sounds good, doesn’t it.

Unfortunately, none of these varieties of medical scheme options mean you have excellent cover.

All it means is that the medical aid is prepared to pay 100% (or whatever percentage) of the listed internal fees they work on.

So if your hospital stay cost R120 000, for instance, and let’s say you are on a 200% medical aid option, then the medical aid will pay twice the listed fee. But what if the internal listed amount is just R30 000? Well, then you are covered for R60 000. You will have to pay the balance out of your own pocket!

That’s known as the co-payment gap, and that’s what gap cover seeks to eliminate.

How gap cover payment works

The gap insurance product is so innovative and saves medical aid members so much money that you would expect it to cost a lot. But it does not. It is highly affordable.

Expect to pay the equivalent of roughly 10% of your medical aid premium on top-up cover. So if you pay R4000 a month on medical aid, then you will probably have to pay in the region of R400 per month for gap cover.

Of course, you can make payment annually if you so choose.


Get your gap cover quote on this page. Just complete and submit the form.
Please remember: Only medical aid members in South Africa qualify for gap cover.

All info was correct at time of publishing