What is Medical Gap Cover?

March 3, 2022

What is medical gap cover? Well, there can be no such product if you do not belong to a medical scheme first. Thankfully many South African families are now acutely aware of just how critical health protection is. Those with children are especially appreciative because children have a tendency to develop sudden illnesses early in life.

What is Medical Gap Cover?


  • Gap cover in South Africa is an affordable insurance product that insures the shortfall between the amount your medical scheme will pay for specialised treatment and hospital stays and the total that appears on the medical bills. The reason for the self-payment shortfall is that specialists and hospitals are permitted to charge what they like.
  • That can amount to 400% of NHRPL benefits. So if your medical aid pays only 100% or 200% of NHRPL fees, then you may have to pay a shortfall amount. This short-term  insurance product covers the difference.
  • Shortfall insurance, otherwise known as top-up insurance, is affordable and one policy covers all the members on the medical aid plan. Get a quote on this page.


But even while medical aid has come to the rescue of South Africans and their dependants, many have found themselves financially battling to pay for medical services beyond the limit of their cover. These unexpected costs are also emotionally draining

Apply for one FREE medical gap cover quote by completing and sending the form on this page. Medical aid members ONLY

There are Several Reasons You can Find yourself Having to pay for Treatment over and Above your Medical Aid Payments

What is medical gap cover?There are some medical scheme options which require you to carry a co-payment while going to the hospital. This is usually an amount disclosed by the medical aid beforehand regarding percentages. 100%, 200% and 300% relate to the proportion of the medical schemes own rates

  • You could have been treated at an institution that is not in your medical schemes’ list, maybe because it was the nearest and you had an emergency.
  • The doctor’s fee in some cases turns out to be much higher than expected (known as a medical gap).
  • You could find yourself, or the beneficiaries of your medical aid, seeking treatment more than you expected thus exhausting your yearly limit.

The agony of having to foot extra expenses even after faithfully contributing premiums through the year is sadly all too familiar for many South Africans. This scenario is becoming more and more common every year with rising medical costs.”What is Medical Gap Cover”? is a question everybody now asks.

What is Medical Gap Cover?

The solution to exorbitant medical expenses is to take the gap. However, there is a solution that will help you get all the cover you need without confronting escalating out of pocket costs. You can enrol for medical gap cover which, you will be happy to know, is available to members of any medical scheme in South Africa. There are Pros –

  • You can access medical gap cover as long as you have medical aid, no matter how basic.
  • Depending on the particular kind of medical gap cover you choose you can have the freedom of selecting the doctor you want.
  • You can keep the medical gap cover even if you change your medical aid.

  and Cons:

  • Depending on the medical aid provider there is an age (usually 60 years) beyond which you will be ineligible for medical gap cover. However, some providers don’t have this restriction.


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Limitations of medical gap cover

 While medical gap cover includes treatment of most kinds of medical conditions, there are some cases where it does not.

  • Claims from those injured while taking part in extreme sports or engaged in military service will not be compensated.
  • Health complications arising from drug abuse or mental illness will also not be treated under medical gap cover.

Before you seek treatment, you need to make sure that the doctor you’ll be seeing is part of your health cover provider’s medical gap cover arrangements.

Apply for your medical gap cover quote by completing and sending the form on this page. Medical aid members ONLY


All info was correct at time of publishing