How Does Co-Pay Cover Work?

Co-payments are yet another one of those built-in costs that can come as a shock to members of aid schemes. Which is why co-pay cover is crucial.


Members of medical schemes think that their hefty monthly fee offers them 100% cover for health costs, but nothing could be further from the truth.


Apart from Co-Payments, health schemes only pay for procedures according to a set tariff rate. This can be five times less than what the medical expert charges.


These shortfalls have to be paid by the aid member, adding huge burdens to cash-strapped family budgets, and surely leading to more debt.


co-pay coverWhat is the solution? Co-pay cover!


These days, members of health schemes would be short-sighted unless they added Gap Cover to their aid.


Gap Cover is a short-term form of insurance that pays the difference between medical scheme tariff and health experts bills.


Gap Cover can also include Co-Pay cover, but this perk can only be added for an extra monthly fee.


What are Co-Payments?

Co-Payments are excess amounts specified by health schemes and the duty of its members.


These Co-Payments include MRI and CT scans, ultrasounds and scopes, as well as hospital admissions.


Examples of Additional Co-Payment Costs


  • Procedures for impacted wisdom teeth can cost members up to R5 250
  • Gastroscopies can cost members up to R3 900
  • MRI and CT scans can cost members up to R2 900
  • Hospital admission fees can cost members R1 200


But, despite cover for Co-Payments, companies have built-in exclusion clauses. These can vary, but generally, include the following:



  • No nuclear cover, including materials, weapons and fallout
  • Cosmetic surgery or obesity treatments
  • Routine physical exams, X-rays or laboratory tests
  • Mental disorders
  • Suicide
  • Drug addiction or medication unless prescribed by a medical doctor
  • Alcohol abuse
  • Cover for members of the military, police, police reservists or active civil uprising, labour unrest, riots, strikes, or the activities of locked out workers
  • Aviation cover unless the policyholder is a passenger
  • Form of speed or race test
  • Costs involved with private nursing


On the PLUS side


  • Co-pay cover is open to clients up to the age of 70 years, granted they are members of a listed medical scheme in SA.


  • It covers all family members listed on the Gap Cover policy, given they are on the same medical aid.


  • It will cover the cost of doctor visits and medicines, as well as co-payment charges by medical schemes for certain treatments.



People should shop around before choosing any specific Gap Cover provider.


There are some companies that include co-payments in the policy without having to add it as an extra benefit.

Despite standard waiting periods for pre-existing conditions, Gap Cover becomes effective the moment the policyholder pays the first premium.

It is also vital to know that Gap Cover remains in force even when members change from one medical scheme to another.

Simply complete and submit the form to get a FREE Gap Cover Quote.


All info was correct at time of publishing