Gap cover – is it necessary?

May 7, 2018

In South Africa medical service providers are not regulated. This means that they are able to charge above the medical aid rate of your specific scheme, unless they have a payment arrangement with your scheme and have signed a contract to charge according to the scheme’s rates.


This may result in a member having to pay a provider over and above what the scheme has paid them for hospitalisation.


While some may have savings, not many people are able to afford upfront payments, which schemes refer to as co-payments before a procedure is done.


Imagine paying over R2000, sometimes even R13 000 depending on your plan and the procedure, from your medical aid savings, or out of your pocket, to a hospital. This takes a huge chunk out of your savings, which you may need for the rest of the year. For those who do not have a medical aid savings account, it could mean that they have to take out a loan or request an advance from work in order to pay the co-payment or deductible. This could result in a member getting into debt.


The core purpose of Gap cover is to assist you with service provider shortfalls in hospital and co-payments to hospitals, should the need arise. There are diffierent levels and types of Gap cover, and the premiums are based on the type of cover that you would like to have. The core benefit covers you for shortfalls that occur in hospital with the medical providers that assist you while you are hospitalised. Should these medical providers charge you above the medical aid rate, gap cover will pay the shortfall up to a specified percentage. There are other benefits that gap cover provides, ranging all the way to cancer cover, trauma counselling, premium waivers and casualty cover.


When claiming from Gap cover it is important to note that they will need the following information:

  • A fully completed Client Claim Form

  • Latest Medical Scheme Membership Certificate

  • All respective supporting documents such as statements from the medical aid and the provider

As these are short term insurance products, and are not governed by the Medical Schemes Act, they may impose exclusions on existing conditions.





Should you require a group or an individual quote, your GTC healthcare consultant will be able to assist you with one.


Jill Larkan

Head - Healthcare Consulting

t +27 (0) 21 412 1062

c +27 (0) 83 453 3344



Share on Facebook
Share on Twitter
Please reload

Featured Posts