How Medical Gap Cover Works

Medical gap cover is the short term insurance product that covers the shortfall in medical bills. Basically medical gap cover pays for those amounts that the medical aid plan will not pay for.

Medical aid plans are essential in South Africa. That is because they provide the peace of mind of knowing that one will access health care. However, medical aid schemes, have fallen short in their ability to pay for health care in full. Members still find themselves burdened with huge bills. Medical aid gap cover, therefore, becomes a necessary insurance add on.

This insurance is available to all South Africans who are 70 years and below and who belong to a medical aid scheme. Medical gap cover is, however, not a medical aid plan. Therefore it is not a replacement for medical aid.

Gap Cover Limitations Too

While gap cover pays primarily for the shortfalls it does not necessarily pay for everything. The benefits by each gap cover will vary by the scheme, with some not paying for certain illnesses such as cancers. It is therefore advisable that members first establish the areas that they will benefit from How Medical Gap Cover Workssigning up with a service provider.

Gap cover schemes protect members from having to pay the difference in medical costs from their own pocket savings. Members have contributed towards their medical aid scheme monthly premiums with the belief that they will have full cover for their health care, only to discover they still owe huge sums of money, because their plan will not pay for certain procedures.

Also, while medical aid schemes are regulated, certain medical practitioners are not regulated. They are free to charge what they please or deem as fair value for their service and this often will be 5 times more than the medical aid plan can pay out in benefits. Members end up having to pay out for the difference from their other savings.


The cover has nothing to do with the council of medical aid schemes. It is rather an insurance package under the insurance sector. Therefore though a member may choose to change medical aid schemes they can keep their medical aid gap cover.

Claiming benefits on the medical aid gap cover follows the procedures set out by the insurer. Generally, however, claims take effect after the medical aid plan has paid for the medical bill. The member has to establish what portion of the bill has been left unpaid and then claim this from their gap cover. The insurer will pay the member directly who then go and pay their health care service provider.

One is not required to take a medical examination to qualify and often members receive immediate cover. Gap cover does not stipulate which medical service provider should be consulted, but it will not cover day-to-day medical services such as visits to a General Practitioner.

Complete and send the form to get a quick, no-obligation gap cover quote


All info was correct at time of publishing