GAP Cover
GAP Cover: Frequently Asked Questions
What is a Medical Aid (medical scheme)?
Gap cover is a short-term insurance product designed to work with your existing medical aid — it is not a medical scheme on its own. It protects you against the financial “gap” between what your medical aid pays (based on Medical Scheme Tariffs) and what private healthcare providers (specialists, hospitals) actually charge — which can be well above the medical aid rate.
Key points:
Only available if you’re a member of a registered medical scheme.
It supplements your medical aid — not replaces it.
Short-term insurance (renewed annually) with limits and conditions set by the insurer.
Core cover:
- Tariff shortfalls: Pays the difference between the medical aid payment and healthcare provider charges (e.g., specialist or anaesthetist fees).
- Co-payments & sub-limits: Covers upfront co-payments, deductibles, and shortfalls where medical aids impose limits (e.g., MRI/CT scans).
- Oncology shortfalls: Some products include additional benefits for cancer treatment once scheme benefits are exhausted.
- Additional benefits (varies by provider): Casualty cover, maternity, prosthesis shortfalls and hospital admission extenders.
Eligibility:
Yes. By law, schemes may apply:
Must have active medical aid membership with a registered scheme in South Africa.
Gap cover is available for individuals and families as long as they are on medical aid.
Underwriting & waiting periods:
Many providers apply a general waiting period (often ~3 months) before claims can be made.
Condition-specific waiting periods may apply (commonly 12 months for pre-existing conditions).
Some providers use age-based premiums or may have age limits.
How it works in practice:
Schemes reimburse according to their tariff (“scheme rate”). Many specialists charge above this, creating a shortfall unless your option covers higher multiples or you have gap cover.
What is gap cover and what’s the annual limit?
- You receive treatment and submit the claim to your medical aid first.
- Once the medical aid has processed and paid its portion, you then submit the shortfall to your gap cover insurer.
Claim submission:
Most gap cover providers require proof of medical aid settlement before assessing the gap claim.
Some products (e.g., certain Discovery Gap Cover options) automatically identify gaps and pay once the scheme claim is processed.
What isn’t covered:
Costs:
Premiums vary widely based on age, benefit level and provider — typically from modest monthly amounts for basic cover up to higher amounts for comprehensive plans.
Premiums are separate from your medical aid contributions and paid directly to the gap cover insurer.
Tax:
Gap cover premiums are generally not tax deductible as medical aid contributions are; gap cover is short-term insurance rather than a medical scheme contribution. (SA Revenue Service typically only allows deductions for medical scheme contributions and certain medical expenses, not short-term insurance premiums.)
Admin tips:
Compare products to ensure you’re not paying for redundant cover you don’t need.
Understand limits (annual caps, per-benefit ceilings) to avoid surprises at claim stage.
Claims & Disputes
Claiming:
Submit the medical aid settlement and original invoices to your gap cover provider.
Timeframes vary by provider; check policy documents for expected turnaround periods.
Disputes:
If a claim is denied or underpaid, request a full explanation in writing.
Review the policy terms to assess entitlement.
If unresolved, lodge a formal complaint with the insurer’s internal disputes resolution process.
As a last resort, escalate through the Financial Sector Conduct Authority (FSCA) or Office of the Ombud for Short-Term Insurance.
