Argument in Favour of Medical Gap Cover in South Africa

Debates may rage on about the need for medical gap cover in South Africa, but the facts are clear.

There are more pros than cons for adding gap cover to medical portfolios.

Fees asked by health experts far outstrip the tariff rates that aid schemes are prepared to cover.

Surgeons, Anaesthetists, pathologists and radiologists are among members of the medical profession whose charges for services rendered leaves the consumer to face huge shortfalls.

What about my medical aid cover?

It is a known fact that many members of aid schemes in South Africa believe they are fully covered for costs involved with health treatments.

Nothing could be further from the truth.

While a medical scheme may state that it pays 100% of health bills, they only pay 100% of standard ceiling rates.

Medical scheme tariffs for different procedures based on prices are recommended by the National Health Reference Price List.

These tariffs can often be up to 500% less than what medical experts charge for their services.

A heart bypass, for example, could cost R350 000, but the medical scheme tariff for this procedure is pegged at R250 000.

The R100 000 shortfall then becomes the burden of the scheme member.

Most families simply do not have that kind of cash lying around.

So what do they do?

Unless they can be helped by family or friends, they have to take out a loan to cover their hospital debt, leaving them deeper in the red.

Medical Gap Cover in South AfricaMedical Gap Cover in South Africa is the answer

Many people may regard gap cover in South Africa as a necessary evil.

But even so, it provides the solution to the financial nightmares faced by families in times of illness.

It answers the need for cash to cover the gap between medical aid rates and private experts costs.

Medical Gap Cover in South Africa is affordable

Unlike aid schemes which cost consumers a big chunk of their monthly budgets, Gap Cover is affordable.

As an example, a family of three has comprehensive gap cover with Zestlife at the cost of R245 a month.

Nowadays many South African short-term insurance companies offer gap cover.

Premiums increase depending on the cover chosen.

The better the benefits, the higher the monthly premiums imposed by the insurance company.

Benefits of Medical Gap Cover in South Africa

Some of the benefits offered by gap cover insurance include:

  • No medical examinations are required
  • It covers the principal policyholder, his spouse or life partner and children, including adopted and stepchildren, provided they are all members of the same scheme


Examples of shortfall benefits

  • Hip replacement surgery – potential shortfall of R66 178 payable by Gap Cover
  • Caesarian section – potential shortfall of R29 618 payable by Gap Cover
  • Natural child birth – potential shortfall of R18 464 payable by Gap Cover

Co-Payment expenses can also be covered. This is when a member has to pay his/her medical scheme upfront for a percentage of the costs involved with an upcoming surgical procedure and hospital admission fees.

Medical Gap Cover in South Africa  – What Are Co-Payments?


Medical schemes specify excess amounts that clients pay in the event of a claim. Co-payments are the financial responsibility of the scheme members. These Co-Payments include MRI and CT scans, ultrasounds and scopes.

Also, remember to read the fine print so that you fully understand the benefits and exclusion clauses built into your contract.

Apply for a FREE quote online if you belong to one of these medical aids. Simply complete and submit the form

All info was correct at time of publishing