Gap cover 101: What you need to know

Oh, we were so excited (and scared) when we found out Mrs Frugal was pregnant with Frugal Jr. As a planned baby, we upgraded our medical aid in advance, to make sure we’d get good coverage for the gynaecologist, scans, hospital requirements and even a c-section if required.

We did everything according to the medical aid rules: we went to a network hospital, visited the gynae at the required times and paid the hospital fee in advance to be claimed back from the medical aid. Oh, the unhappiness when we discovered that the medical aid only covered 33% of the c-section! We had to pay the other 67% from our own pockets!

Enter gap cover.

How do medical aids decide how much to pay?

We didn’t know it at the time, but each treatment has a number assigned to it. The National Health Reference Price List or NHRPL is a comprehensive list with the ICD-10 codes. This price list is a guideline for what health professionals should charge for their services. The Department of Health (DoH) revises these tariffs annually by consulting the medical industry – and when these prices go up, so does your medical aid contribution.

In many circumstances, this is just not achievable. For example, the rent on-premises and other fees might cause a loss if this fee is charged. For example, a gynaecologist needs to pay more than R 1 million per year for insurance against something going wrong and high rent for her consultation room at the hospital.

How does gap cover work?

The discrepancy between the NHRPL and the fees charged by health professionals is why we have a shortfall or gap that the patient will be held liable for. Gap cover aims to step into this gap by paying what the medical aid does not cover – or a percentage of it.

Medical insurance vs medical aid

In some instances, you might be hospitalised for a long period of time. During this time, you might not get a salary or any income. In this instance, you can opt to get medical insurance.

Medical aid ensures you are covered if you need to be hospitalised, have a chronic condition under prescribed minimum benefits or need day-to-day benefits. However, medical insurance ensures you receive a pay-out if you are hospitalised and cannot work or earn a living

ProfMed – What is the difference between medical aid and medical insurance?

Medical insurance is not the same as gap cover!

Gap cover vs medical aid – the differences

To simplify, let’s look at the key differences between gap cover and medical aid:

Gap Cover

  • Gap cover is optional, but requires you to be part of a medical aid
  • Gap cover is underwritten by short-term insurance companies.
  • Where your medical aid doesn’t cover a procedure fully, gap cover will pay a certain percentage of the gap.
  • Depending on the gap cover you take – it can pay for certain specialists and procedures that your medical aid doesn’t cover at all.
  • Generally, gap cover is only for in-hospital treatments. If you visit a doctor with consultation rooms in a hospital, this isn’t covered.

Medical Aid

  • It is optional to have medical aid in South Africa for now., as the NHI has not been finalised as yet.
  • Medical schemes need to be registered with the Council for Medical Schemes.
  • Medical aid covers the national prescribed minimum benefits (PMB) and other benefits as defined by the scheme.
  • Medical aid pays NHRPL rates unless otherwise stated.
  • Depending on the plan, medical aid could cover the PMB of general practitioner/medical specialist visits and other outpatient care as well as in-hospital care.

Who is eligible for gap cover?

If you want to get gap cover, the following criteria must be met:

  • You are a registered member of a South African Medical aid
  • Only having health insurance and not medical aid will not be able to apply for gap cover.

The following are generally eligible, but please check with your gap cover provider:

  • Main members, their families and children up to 27 years of age are covered.
  • Dependents such as parents can be included.
  • If the family has two medical aids, only one gap cover policy is required

Why do we need cap cover?

If you have enough money in your emergency fund to cover shortfalls, you technically don’t need gap cover. We should be cognizant of the fact that medical aids most often only pay out a percentage of the total costs, as per the ICD-10 codes.

In the case of an unplanned pregnancy or a medical crisis such as being diagnosed with cancer, you will need to fit the gap’s bill. If you won’t be able to afford this, you need to consider cap cover.

Note you can’t backdate the gap cover!

What you might also want to know about Gap Cover

It’s important to note that if you’re already pregnant, you can get gap cover – however, there is generally a waiting period of 8-12 months before you can claim for pregnancy-related expenses. Therefore, make sure you get gap cover before you fall pregnant.

Some gap cover options also have cover for Medical aid Co-payments, Sub-limits and cancer treatment shortfalls. In other cases, it might even cover some specialist visits where your medical aid does not. It’s best to read the fine print and also speak to a professional about the details.

Will gap cover always pay out the full gap?

Unfortunately, no company will infinitely insure anyone. Gap cover providers tend to display their coverage as a percentage of the scheme rates. If your medical aid benefits are paid out at 100 percent of the scheme rate and you have a gap cover policy that pays out two times (200 percent) the rate, you may still be personally liable for a portion of the costs.

Let’s look at an example to illustrate this. So you have a medical procedure in hospital. The bill comes and is a total of R 30 000. Submission to the medical aid states that they will only pay out R8 500. If your gap cover is 200% of the procedure, then it pays out R17 000 (R8 500 x 2) leaving a payment gap of R4 500.

In some cases, the gap cover provider might state that a gap of up to 500 percent of the scheme rate will be paid out – and imply that the procedure is covered in full. Note that if the gap is less than 500 %, the excess is not paid to the policyholder.

How do I claim from gap cover?

The payment process can vary depending on the specific gap cover provider. When claiming, you need to first put it through your medical aid. The medical aid will either decline, pay a portion or the full amount. If the medical aid doesn’t pay the full amount, you can claim from your gap cover provider for the remaining amount.

Depending on the provider, you might be required to pay for the amount yourself first, or first submit the claim to them before the bill gets paid. Please make sure how your provider does this, as doing this incorrectly might cause the gap cover not to pay out.

Ultimately, you, the individual is responsible for any co-payments or deductibles.

What does gap cover not cover?

Although there are exceptions, gap cover does not cover all excess costs. Here are some of the exclusions:

  • consultations before and after in-hospital treatment (e.g. gynaecologist visits before and after birth)
  • medication and disposable items in and out of hospital, crutches and wheelchairs
  • private or home nursing
  • depression and other mental health disorders
  • any procedure within the waiting period (e.g. pregnancy)
  • claims older than six months

Does gap cover pay out for visiting specialist doctors?

Some gap cover providers in South Africa will cover the cost of visiting specialist doctors, as long as the medical aid plan also covers it, but it’s important to check with the specific gap cover provider to see what is covered under their policy.

It is worth noting that gap cover providers may have different policies on what they will cover, and some may have exclusions or limits on certain types of medical expenses, such as visiting specialists. It is important to read the policy details carefully or consult with the gap cover provider to understand what is covered and what is not.

Note that consultations with specialists who have rooms at the hospital are not seen as in-hospital care, and therefore, many gap cover policies won’t cover this. There might be times be a requirement for a non-emergency specialist treatment while in hospital. In many cases the medical scheme would pay its tariff and the patient will need to pay the gap themselves. Once paid, a gap cover claim can be submitted.  


In conclusion, gap cover serves as a vital financial safeguard, covering expenses not met by medical aid. Understanding its intricacies ensures effective financial planning and peace of mind during medical emergencies.