Medical Gap Cover and Medical Schemes

What is medical gap cover?

  • Medical gap cover protects policyholders from financial shortfalls
  • Medical schemes are under financial strain
  • Debate continues to rage between product providers
  • Gap cover is now under scrutiny
  • Speak to a broker for advice

The debate rages on

Shortfall insurance is an ongoing subject of heated debate between medical schemes and short-term insurance providers.

Significantly, medical schemes blame the popularity of gap cover on the dwindling number of people opting for comprehensive medical aid.

They believe this trend started because of the substantially cheaper monthly premiums for gap cover insurance.

Medical schemes feel that consumers are downgrading their medical aid benefits. They are supplementing those shortfalls in health care cover with the benefits of gap cover.

Medical Schemes and Gap CoverShort-term insurance providers, on the other hand, believe that gap cover offers lower income earners essential medical services and therefore provides a much-needed health care package.

Also, insurance providers argue that the abolition of gap cover would probably result in fewer people opting for medical aid because of the high monthly premiums.

But allowing gap cover to continue providing a much-needed medical product would probably encourage lower income earners to continue their membership of medical schemes.

This ongoing battle has led to government intervention and gap cover is now under review.

Medical schemes are under financial strain

Medical schemes are fighting to maintain the cost of covering medical expenses. That is caused by an increasing number of people opting for the cheapest package available.

Consumers then make up for this shortfall in medical cover with affordable gap cover insurance policies.

This phenomenon has placed medical schemes in a position of not being able to fully cover all medical treatments.

They have imposed co-payments on their members and work to tariff ceilings that more often than not are well below what the medical profession charge for their services.

The impact of PMBs

The South Africa Council for Medical Schemes’ Prescribed Minimum Benefits (PMBs) has further impacted on medical schemes.

In terms of this regulation, all registered medical schemes must provide its members with PMBs that encompass almost two hundred medical conditions, including 27 chronic conditions.

Medical schemes are legally obliged to cover all expenses related to PMB conditions, as well as cancer treatments and medical emergencies.

Who are gap cover providers?

Most of the leading short-term insurance providers offer gap cover, including companies such as:


Medical schemes are under increasing financial strain to cover the cost of claims submitted by members for medical treatment.

This trend has led to substantial shortfalls between medical scheme tariff ceilings and bills imposed by members of the medical profession for services rendered.

Gap cover cover shortfalls, making it an extremely attractive and affordable product to supplement individual health care portfolios.

Consumers are urged to speak to a broker for advice before selecting a product.

All info was correct at time of publishing