Limits to Gap Cover

What are the Limits of Gap Cover?


  1. Limits came into effect April 2017 with regards to max payouts permitted
  2. Policies will all have to comply with these regulations in 2018
  3. Those insurances where you receive a daily cash amount while you’re in hospital. They must be a max amount of R3 000 for each day or R20 000 a year
  4. Gap cover policies are limited to a payout amount of R150 000 each year and for each client
  5. Each gap cover is different. The limits depend on the insurance provider and your chosen policy
  6. As with medical aids, gap covers have waiting periods too for things such as pre-existing conditions as well as a general waiting period
  7. Gap covers have exclusions so you need to read your policy document


Medical Gap Cover DOESN’T cover everything you Thought it Would

Medical aid members who invest in gap cover believe that this gap cover is going to cover them for Limits to Medical Gap Covereverything. This isn’t the case. Everyone with medical aid buys gap cover because it is required to pay the shortfall between what the medical scheme pays and what the specialist charges.

These gap cover providers differ because some pay up to 2x what the medical scheme has paid, while others up to 5x – it all depends on the policy you have.

There Are Limits on Newer Policies

In 2018, all medical aid members who have gap cover policies will be able to go on enjoying the  benefits they have with their current gap cover. However, those who bought gap cover after April 2017 will have a R150 000 overall annual limit for each beneficiary.

You have do do research because there is gap cover which won’t have Primary Care benefits such as optometry, dentistry, GP visits, chronic medicines and emergency medical services.

Gap cover is still a good deal though because just one policy takes care of the main member and their dependants who are on the same medical scheme. So you’re paying just once.

There are other things you need to be aware of that gap cover won’t pay for, some of which are –

  • ward costs in a hospital
  • pre-admission consultation costs
  • mental health disorders
  • cosmetic procedures
  • private nursing
  • external prostheses
  • medical accessories such as crutches and wheelchairs
  • not all gap cover takes care of co-payments


You NEED Gap Cover

The truth is, if you want good medical care in South Africa you need a medical aid and you need gap cover, especially as specialists’ fees aren’t regulated in South Africa. Medical aid’s have therefore created a cap on the amount of cover they’re prepared to fund.

Most gap cover providers align themselves with the benefits of a medical scheme, basing their cover on the benefits of the scheme.  

In 2018, gap cover with its limitation is still of critical importance. Without it you could be having to pay massive medical bills your medical aid won’t pay. When you look for medical gap cover, try and go for the ones that offer 500% medical aid rate cover. Another important thing to look out for is a co-payment benefit, because without this, you will have to pay an amount upfront if you want your treatment to begin.

Know what your Policy Includes and Excludes

Medical aids and gap cover can be complex. With any new policy, don’t be lax when it comes to reading and understanding what it lays out for you, and more importantly, what it doesn’t.

Next step: complete and submit the form on this page to get a quote (if you are a medical aid member in South Africa)


All info was correct at time of publishing