PMB’s and Gap Cover in South Africa

December 18, 2021

here are going to be several changes to Gap Insurance cover in the near future. They give us gap cover to make up for shortfalls that policyholders may experience when their Medical Scheme does not pay out enough to cover the difference between Specialist /Doctors fees and the amount the medical aid will pay. The affordability of Medical Schemes and the type of care that companies offer by the State has a major impact on South African Health Insurance.The policy amounts that the Gap Insurance Industry pays, is growing even with PMB’s. PMB (Prescribed Medical Benefits) are a list of conditions and treatments that the government requires that all Medical Scheme’s in South Africa must adhere to and cover in full if PMB conditions are met.  Read on to find out more about pmb’s and gap cover.

History Gap Insurance – Pmb’s and gap cover

This insurance is regulated by 2 Acts:

  • Long Term Insurance Act ( 52/98)
  • Short Term Insurance Act ( 53/98)


Discussions held between the Medical Schemes, Government and the Insurance Industry.

  • pmb’s and gap coverFinal Demarcation Document was published on 28th October 2016.
  • Implementation on 1st April 2017.
  • New policies will adhere to these regulations from 1st April 2017.
  • Policies that already exist have until Jan 1st 2018 to change.


Pmb’s and gap coverMain points of Change: 

  • “Gap” will change to “Medical Expenses Shortfall Products”.
  • They will cap Broker fees at 5 – 20% that have to do with premiums.
  • Community rating will apply – No discrimination allowed for people wanting to take out this insurance.
  • Marketing of the product strictly controlled.
  • Limit to R 150 000 per person.
  • No direct payment of specialist/doctor by insurers.


Likely effects on the changes in policies – Pmb’s and gap cover

There is a marked increase in payouts against shortfalls on PMB conditions.

  • Community rating means that insurers will in all likelihood increase their premiums as they will no longer be able to adjust for the risk element
  • Insurers will offer policies that do not cover PMB’s shortfalls. One of the biggest “Gap’ Insurers Guardrisk has already changed their Admed scheme. One option is that they will reduce the premium up to 27%. Although they will not cover shortfalls from PMB conditions.
  • Many new policies will not cover the PMB shortfall (and many others not PMB) where the policyholder deliberately did not use the Designated Service Provider appointed by the Medical Aid scheme. They will still exclude emergencies.
  • Waiting Period In the past, some members joined a “gap” insurance scheme only when they were going to have surgery, etc. The will closely control the new general and specific wait periods.


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All info was correct at time of publishing