Choosing between some of the best Gap Cover suppliers in South Africa
After figuring out all the levels to finding the right Medical Aid for you and your family, the “final boss” is Gap Cover. While Medical Aid can be crucial for covering private, specialist healthcare, many plans fall short of paying the full amount. With medical costs consistently rising, Gap Cover is your "all bases covered" solution to make sure you’re not caught short and have to pay out of pocket when specialists charge above Medical Aid rates.
NOTE: Gap Cover is an addition to your Medical Aid, not a replacement for it. It provides additional financial protection, covering the gap between your Medical Aid Scheme Rates and what specialists charge.
What is Gap Cover?
Gap Cover’s name says it all. Private medical care is already expensive to begin with, never mind it going up all the time. The “gap” is the difference between what a specialist doctor or hospital charges and what your scheme pays. According to the Consumer Price Index, medical prices have increased at 2% above the annual inflation rate of 3.6%, where with some specialist procedures a scheme may pay up to 200% while a provider may charge up to 500%, leaving you to fund the shortfall without Gap Cover. As such, Medical scheme members’ out-of-pocket payments are also growing. The CMS (Council of Medical Aid Schemes) reports that total out-of-pocket payments members paid increased from R27.2bn (2015) to R46.3bn (2024). That’s one of the main reasons why South Africans need to consider adding Gap Cover to their medical cover portfolio.
Note: You can only qualify for Gap Cover if you are with a Medical Aid Scheme.
Why get Gap Cover?
Medical Aids adhere to their own rules, Medical Scheme Rates (MSR), and benefits when paying claims. However, actual healthcare costs often exceed the Medical Aid rate, leading to a shortfall.
Gap Cover helps bridge this gap by covering the difference between what your Medical Aid pays and the full cost of in and out-of-hospital fees.
What to consider with Gap Cover
- There’s a legal yearly payout limit (annual aggregate limit)
- Gap Cover is regulated under Demarcation Regulations
- The cap is the maximum payout per insured person per year
- Even large claims cannot exceed this cap
- Policy-specific limits also apply (per event, per claim type, per year)
- You are working within both legal caps and insurer limits
Treasury’s Category 1 annual cap moved as follows:
- R210,580.06 (1 April 2024)
- R219,845.96 (1 April 2025)
- Updated annually from 1 April 2026
How much can Gap Cover cost?
Gap Cover can be an essential addition to your Medical Aid. Although you can choose a premium tailored to your needs, below are entry-level plans from partners.
| Provider | Entry level gap cover option | Starting premium | Medical aid tariff shortfall covered |
|---|---|---|---|
| Total Risk Administrators (TRA) | Basic Cover 300 | From R99 pm | Up to an additional 700% of medical aid scheme tariff |
| Auto & General | Essential Gap Cover | From R99 pm | Up to an additional 700% of the medical scheme tariff |
What Gap Cover covers and what it doesn’t
As with any insurance product, they come with their own set of terms and acronyms, and the more familiar you are with them, the better decisions you can make. While each policy offering differs, below is a table showing what Gap Cover typically does and doesn’t cover.
| Typically covers | Typically doesn’t cover |
|---|---|
| Tariff shortfalls (what the provider charges vs what your medical scheme pays), within limits | Anything above the legal annual cap (e.g. R219,845.96 per insured person per year) |
| Some co-payments for specific procedures/scans (depends on the plan) | Costs your medical scheme doesn’t recognise / doesn’t pay at all |
| Optional extras on some policies (e.g. dental benefits) | Everyday medical spending (GP visits, scripts, etc.) unless included |
| Anything excluded by waiting periods, exclusions, and policy definitions |
NOTE: Gap Cover is not a Medical Aid, nor a substitute for Medical Aid. It complements your existing plan by covering the difference between what Medical Aid pays and what specialists charge.
Looking to cover the gap? Consider Hippo to compare Gap Cover quotes
Hippo not only finds you the perfect price and value for your Medical Aid, but also for Gap Cover as an add-on benefit. It only takes minutes and isn’t reliant on you having selected your Medical Aid using Hippo.
Remember, Gap Cover is an add-on that costs a relatively small amount per month and can save you a fortune when medical bills exceed what your Medical Aid covers.
This article is for informational purposes only and should not be construed as financial, legal, or medical advice. Coverage terms, pricing, and availability may vary. Always review policy documents carefully and confirm current pricing with providers before making any decisions.
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