Medical Aid Shortfall Cover – Explained

Imagine a situation where due to an illness or accident you end up in a hospital. The last thing you should worry about is how to come up with the money for the treatment needed. Medical aids are going to cover part of the cost, but will not offer full coverage for a list of medical procedures. You have to pay the difference between the hospital bill total and the sum your medical aid scheme will pay.  You may plan ahead and save up the needed amount. But you may not have time for that when there is an accident or a sudden illness. The shortfall can be as high as tens of thousands of dollars. And that is why you need medical shortfall cover from an insurance company.

Therefore more informed people in South Africans have been taking out gap shortfall cover insurance. That is a product that covers the shortfall between what your medical insurance covers and what the doctor charges you.

What is medical aid shortfall cover?

Your medical aid establishes a medical aid rate. That rate is the base for what medical practitioners can charge for all kinds of procedures.

While certain high-end medical aids offer up to 300% of this rate, hospitals and specialists are free to set their rates higher Shortfall Cover for Medical Aid Membersthan 300% rate. For instance, a surgeon may charge 00% of medical aid rates, then the medical aid covers the 300% and you are left having to pay the remaining 100%.

Working in combination with your medical aid cover, gap cover guarantees to pay for that difference: the shortfall between what the medical practitioner charges and what your medical aid scheme will pay for. Continuing with the above-mentioned example – gap cover would pay for the remaining 100% for you.

Note that gap cover does not pay for the treatments that are excluded by your medical aid (i.e. cosmetic surgery, dental surgery, etc). It will only cover the shortfall on those procedures and medications which are approved.

Check your shortfall cover contract

You should make informed decisions and read the fine print to make sure you know all the details. Take into account the percentage that medical aid rates go up to, as well as any exclusions that exist in the scheme.

In case you decide gap cover is the right choice for you, you should then pick the most extensive one. You might as well be as fully covered as possible. Besides, you will be pleasantly surprised by the benefits that come with gap cover.

Certain gap covers will even provide dental benefits for an add-on fee. But before you make your final choice, remember that those usually include in-hospital dental treatments only.

The bottom line

To put it simply – having gap cover gives you total security. You don’t need to worry about the cost of unexpected medical emergencies. You and your family can live a happy and healthy life, stress-free. There is zero chance of you ending up in a situation where you need to come up with a large amount of money to pay for a life-saving procedure. Gap cover relieves you of these pressures. Moreover, the premiums are affordable and the benefits provided are comprehensive. All in all, there is no excuse not to take out gap cover to protect yourself and your family.


Gap cover is for medical aid members only! If you belong to a medical aid, please complete and submit the form on this page to get a Zestlife gap insurance quote.

All info was correct at time of publishing