Gap cover: the insurance nobody explains at your first job
Medical aid doesn't always pay what specialists charge. Gap cover fills the difference — here's how it works and when it's worth it.
5 min read
You have medical aid, so you're covered, right? Mostly. Until a specialist charges five times what your scheme pays — and the difference is your problem. That difference is the "gap".
The problem gap cover solves
Medical schemes pay for in-hospital treatment at a set benchmark, often called "100% of scheme rate". But specialists (anaesthetists are the famous example) can legally charge 300–500% of that rate. The shortfall is billed to you.
A simple example:
- Anaesthetist charges R16,000 for your appendix surgery
- Scheme rate for the procedure: R4,000 — that's what your medical aid pays
- You owe R12,000
What gap cover is
Gap cover is a separate, cheap insurance policy (it's short-term insurance, not a medical scheme) that pays that shortfall — typically covering up to 500% or 600% of scheme rates. Premiums for a young professional are usually R150–R400 a month, a fraction of medical aid premiums.
What it generally covers:
- In-hospital specialist shortfalls (the classic case)
- Co-payments on scans, procedures, and some hospital admissions
- Sometimes: cancer treatment shortfalls, casualty visits
What it doesn't:
- Day-to-day costs — GP visits, medicine, dentists (that's your medical aid's job)
- Anything when you don't have an underlying medical scheme (you must be on one)
- Pre-existing conditions during waiting periods (usually up to 12 months)
When it's worth it
Gap cover makes the most sense if you're on a hospital plan or lower-tier medical aid option — exactly what most young professionals choose. Those options use lower scheme rates, so shortfalls are bigger and more likely.
If you're on a top-tier plan that already pays 200–300% of scheme rates, the gap is smaller, and the case is weaker.
How to shop for it
Compare on four things: the multiple covered (500%+ is standard), the annual claim limit (regulated maximums apply, adjusted over time), waiting periods, and co-payment/casualty benefits. Read the exclusions page — it's usually only one page.
Gap cover is one of the highest-value-per-rand insurance products for young, healthy people on entry-level medical aids. It's also one of the least explained. Now it isn't.