Gap Cover – Finally what’s Gap Cover all about is revealed here!

Frequently asked questions about Gap Cover always come up. Many people are still unsure of what Gap Cover is all about.

Frequently asked questions about Gap Cover

  • What is Gap Cover? It’s a policy that pays the difference between the amount charged by a Medical Professional and the amount your Medical Aid Scheme pays while you are in hospital.
  • The maximum amount paid calculated at 500% the medical scheme tariff.
  • Is there an annual limit on my policy?

Yes, R150 000.

  • Why do I need gap cover?

Specialists can charge at a much higher rate than the standard scheme rate. Therefore, everyone needs extra cover to be able to fund the shortfall. The actual cost of treatment and a stay in hospital may well exceed the 150% or 200% offered by a medical plan, however, costs can go over 500%.

Frequently asked Questions about Gap Cover and Payment shortfalls

Procedure and Amount charged by service provider:

1.    Colonoscopy  R3 700 / Potential Shortfall R1 108

2.    Back Fusion  R41 231 / Potential Shortfall  R18 201

3.    Tonsillectomy R4 138 / Potential Shortfall R1 776

4.    Joint Replacement R35 280 / Potential Shortfall R18 180

Frequently asked Questions about Gap CoverCan I combine Gap With any Medical scheme?

Yes. Our Gap cover policy works with all registered medical schemes in the country.

What is Co-Pay Cover?

CoPay offers cover for hospital admission fees and co-payments, both in-hospital and out. This includes Radiology, MRI and CT scans, with a limit of R12 000 per procedure. Plus, you get R12 000 cover for the co-payments related to non-DSP Hospital, with a limitation set at one event per year.

Some In-Hospital examples :

Gastroscopy – co-payment of R1 300

MRI/CT scans – co-payment of R2 150

Hospital admission fee – co-payment of R1 300

Removal of impacted wisdom teeth over the age of 13 – co-payment of R5 650

Impacted wisdom teeth removal – co-payment of R1 300

Some Out-of-Hospital examples :

Gastroscopy – co-payment of R3 900Scheme

MRI/CT scans – co-payment of R3 050

Does Gap cover Co-payments?

Co-payments not automatically covered. But it is one of the add-on options.

What is The difference between Gap Cover and CoPay?

Gap Cover pays the shortfall between your medical scheme and the cost of your hospital fees. The maximum is as high as 500% of the rates.

CoPay Cover takes care of the treatment that are either in-hospital or out-of- hospital. It involves co-payments or the amounts listed in your medical insurance policy. For instance, Specialized Radiology and CT scans.

What does the term “Combined cover” mean?

It means Gap Cover and CoPay combined.

Which firms Sell Gap Cover?

Western National Insurance and Insuremed Administrators.

What are CoPay cover benefits?

Co-payments for procedures performed as an In-Patient or as an Out-Patient, admission fees, Ultrasound, MRI, PET, SPECT and CT Scans. A set limitation of R12 000 on a singular event basis.

Are day-to-day Services covered?

No, regular health check-ups with the GP, as well as other services not included in the list of benefits.

Does it cover PMB?


What is a PMB?

Prescribed Minimum Benefits (PMB) put in place to guarantee access to minimum health service regardless of the benefits already chosen. The purpose is to give members care they can afford and that benefits their health.

They are a feature of the Medical Schemes Act. The schemes have to cover the costs related to the diagnosis, treatment and care of any emergency medical condition. 270 medical conditions (defined in the Diagnosis Treatment Pairs) and 25 chronic conditions as defined in the Chronic Diseases List.

What are The policy exclusions?

Click her to see the policy document. You will be able to view the full list of the exclusions in a standard policy.

How much do Gap Cover and CoPay Cover cost?

See the option premiums in the application form.

Do fee Increases apply to the Gap Cover and CoPay?


Are there any Additional costs?

No, admin costs come in every month as part of your premium.

When do I pay the First premium?

Within the first month of taking out the cover. See details on debit order dates in the Application form.

Is the Gap Cover fee Paid with the Medical scheme fee?

No, it is separate from it as a different insurance product by another company.

What if the Debit order Falls on a Weekend or public holiday?

The amount gets deducted on the following working day

Who can apply for Gap Cover and CoPay Cover?

Anyone registered as member of the South African medical scheme.

Do I have to Go for a medical Exam to qualify?


Who does This policy cover?

You, your partner and children registered as dependents on your medical scheme. Unregistered dependents not included in the cover.

Do I have to Register my dependents On my policy?

Yes. Please see the Policy Wording to confirm the rules of a valid dependent.

Is a newborn Baby covered?

Yes, and there are no waiting periods – they are covered from birth as long as registration took place within 30 days from birth. However, if registered after 30 days, waiting periods apply.

Is my new Partner covered?

The cover includes your new partner.

Can I add More than One partner?

No, rules only allow one partner to register as a dependent.

When do I receive My policy Documents?

One week after registration has taken place. Note that your application form should be completed in full.

When does Gap Cover come into Force?

The 1st day of the month on receipt of your first premium.

When can I submit a Claim?

As soon as your medical scheme has paid their portion of the account, but no later than four months after the medical scheme payment.

What documents Do I need?

You will need to fill in a claim form, which you can request or CLICK HERE,

Other attachments include:

  • Copies of all relevant doctors’ accounts
  • A clear copy of the hospital account
  • Medical Scheme claim statement showing the shortfall to the doctor
  • A copy of your medical scheme
  • Your Medical Scheme membership certificate

Who gets The payment?

Payments on all claims made into your debit order account. You need to provide proof of banking details with your claim. This is in case the details of the debit order listed on the policy are different from the bank details for claims payment.

If my Details change What must I do?

Send us the changes in an email [email protected] within 30 days of them taking place. Include a copy of your medical scheme membership plan.

Are there New waiting periods if I switch From one Scheme to another?

No. Even though a Gap Cover policy is combined with a medical scheme, the waiting periods are not affected.

When does Gap Cover end?

You must cancel it in writing or when you allow the policy to lapse.

How do I cancel the Policy?

You need to give the firm one month’s notice, in writing.

Can the Policy cancel Automatically?

Once three consecutive premiums have lapsed.

Can a policy be reinstated?

Yes, you can reactivate it within three months from the cancellation date. But you have to submit a new application, in case the policy has been cancelled for a period longer than 3 months.

What is An incident or Event?

Here is an example: If you are a member of a medical scheme and you suffer from persistent migraines. Your GM requests an MRI (co-payment of R1 910 applies). The MRI indicates bleeding on the brain and you then go to hospital, the admission fee is R1 100. While having treatment, the second MRI (co-payment of R1 910) shows that you also require an operation.

All of the co-payments for the mentioned scans and the admission cost are viewed as one event.

Frequently asked questions about Gap Cover – Can I claim for Co-payments on GP visits and Medication?

CoPay Cover supplies cover for identified co-payments related to procedures and scans which are performed in or out-of-hospital. But co-payments on medication and medical consultations are not part of the cover.

What underwriting Is applied to new Policies?

There is a waiting period of three months. It will apply accordingly to all the claims received during this period. It will not apply only in case your claim is as a result of an accident.

When it comes to pre-existing conditions there is a 12-months-long waiting period. We will note any previous cover with similar benefits when making calculations on your waiting periods.

All info was correct at time of publishing