What gap cover covers
What does gap cover cover in South Africa?
Gap cover pays the shortfall between what specialists and doctors charge for in-hospital treatment and what your medical aid actually pays. It also helps with certain co-payments and sub-limits. It works alongside a medical aid, not instead of one, and covers mainly in-hospital costs, so it closes the gap that can leave you with a large, unexpected bill.
Key takeaways
- Gap cover pays the difference between specialist charges and medical aid rates in hospital.
- It can cover co-payments and certain sub-limits your scheme applies.
- It works with a medical aid, not as a replacement for one.
- Cover is mainly for in-hospital treatment, not day-to-day costs.
- Benefits and limits vary by policy, so read the wording.
The shortfall gap cover closes
When you are treated in hospital, specialists often charge more than the rate your medical aid pays, sometimes several times the scheme rate. Your medical aid pays its portion, and you are left with the difference. Gap cover is designed to pay that in-hospital shortfall, so a big bill from an anaesthetist or surgeon does not land on you.
Co-payments and sub-limits
Beyond rate shortfalls, gap cover often helps with two other costs:
- Co-payments, the fixed amount a scheme makes you pay towards certain procedures.
- Sub-limits, where a scheme caps what it pays for things like internal prosthesis or scopes.
Cover for these varies by policy, so check exactly what your gap cover includes.
What gap cover does not do
Gap cover is not a medical aid and cannot replace one. You must belong to a medical aid to have gap cover, because it tops up what the scheme pays rather than paying from scratch. It also focuses on in-hospital treatment, so everyday costs like GP visits and medicine generally fall outside it. See gap cover versus medical aid for how they fit together.
Reading the fine print
Gap cover policies differ in what they pay and their annual limits, and there are regulatory caps on how much cover can pay. Check the overall annual limit, any waiting periods, and whether cancer treatment and specific procedures are included. Then compare quotes for cover that matches your scheme. This is general information, not financial or medical advice.