Many of us on a Medical Scheme are under the impression that when admitted to Hospital for minor or major surgery as a result of an illness or accident that the full cost of the bill will be settled by our respective Medical Scheme. Think again, the reality is that most of us are exposed as Medical Aid options have varying rates of reimbursement. An increasing number of Medical Scheme members are turning to Gap Cover Insurance to give them “peace of mind” that their medical bills will be settled in full.

In South Africa, Medical Scheme’s have different options with varying degrees of reimbursement.  When choosing a medical aid option, you will see that professional services (such as the surgeon or anesthetist) in hospital will be reimbursed at either 100%, 200% or 300% of the scheme rate.  Now anyone will be forgiven for assuming that being covered at 100% means exactly that – you are fully covered!  However, the reality in South Africa is that the majority of specialists in private practice belong to a body called the South African Medical Association (SAMA) and are not regulated as to what they can charge patients for their services, and could charge in excess of the 100% rate which medical schemes are willing to pay – sometimes as much as 500% of the scheme rate!  The end result – the patient ends up with a short-fall on the specialist’s account, which he/she has to pay out of his/her pocket. To illustrate here are two examples of shortfalls in cover:

Tonsillectomy and Adenoidectomy

Attending Doctor Privates Rate Medical Aid Rate Gap Cover
Ear, Nose and Throat Surgeon R6 437.40 R2 526.80 R3 910.60
Specialist Anaesthesiologist R2 231.40 R743.43 R1 487.57
Total R8 668.80 R3 270.63 R5 398.17

Triple Coronary Artery Bypass

Attending Doctor Private Rate Medical Aid Rate Gap Cover
Specialist Cardiothoratic Surgeon R33 305.73 R19 958.15 R13 347.58
Specialist Anaesthesiologist R18 032.78 R7 876.11 R10 165.67
Total R51 338.51 R27 825.26 R23 513.25


What is Gap Cover Insurance?

In short, Gap Cover Insurance is the difference between what specialists charge in hospital, and what’s covered by your particular Medical Scheme option.

It is important to note that Medical Schemes in South Africa are not allowed to offer Gap Cover Insurance products. These products generally fall under the Short-Term Insurance Act.

The majority of Gap Cover Insurance underwriters cover the Gap up to 500%. Simply put if you are on an Medical Aid Option that pays at 100% of the Medical Scheme Tariff and your specialist charges 400% in-hospital the Gap Cover Insurance Company will pick up the differential of 300% (Specialist charge 400% less Medical Scheme portion of 100% = 300% differential).

Depending on your medical aid option, the shortfalls you may experience whilst confined to hospital for a procedure/surgery are as follows:


This is the difference between what your medical scheme is prepared to pay (EG. 100%, 200% or 300% of scheme tariff) and the actual surgeons and specialist charges. Selected Gap Cover Insurance products will cover the difference, up to maximum 500% of the scheme tariff.


This is a portion of the cost of an admission/procedure/investigative procedure as listed by the scheme which the member is required to pay (EG. MRI/CT scans, back surgery, hospital admission fee, etc). Selected Gap Cover Insurance products provide cover for these listed amounts.


These are limitations imposed by the medical scheme on its members (as listed) for in-hospital procedures (EG. Internal Prosthesis). Selected Gap Cover Insurance products provide an amount to assist with sub-limit shortfalls.


Most schemes today will fund a limited amount towards Chemotherapy, Radiation and Cancer Biological drugs. Gap Cover Insurance provides an additional amount to assist with shortfalls on these treatments.

Gap Cover Insurance will NOT provide cover for the following:

  • External Prosthetics
  • Hospital accommodation
  • Exclusions and procedures excluded by medical aid scheme
  • Day-to-day consultations (out of hospital) with doctors/specialists/dentists/optometrists, etc
  • Drugs/medication/bandages/disposables/spectacles, etc
  • Pathology (blood tests) and general diagnostic radiology (x-rays) out of hospital
  • Penalties levied to members by medical scheme for use of non-network hospitals, non-authorization, etc.

Ask Yourself These Important Questions:

  • Are You A Member Of A Medical Scheme?
  • Is Your Medical Aid The Only Financial Plan In Place To Cover The Costs For You And Your Family When Hospitalised Due To An Illness Or Accident?
  • Are You unable, At Short Notice To Secure Funds With Which To Pay Medical Aid Shortfalls Or Gaps When Hospitalised Due To An Illness Or Accident?
  • Do You Want “Peace Of Mind” In Knowing That, In the Event Of Being Hospitalised Due To An Illness Or Accident You Can Guarantee Payment For The Best Care And Services Up To 500% Of The Medical Aid Rate?

Any Yes response means that you should be talking to an Industry Professional who can help guide you in making and Informed Gap Cover Choice over and above your current Medical Aid cover, and more importantly avoid the stress of what we call “Post-Operative Expense Shock

Gap Cover Enquiry