GAP Cover: Frequently Asked Questions
1. What is Gap Cover?
Gap Cover is a short-term insurance product designed to cover shortfalls between what your medical aid scheme pays and what private healthcare providers charge in-hospital.
2. Why do I need Gap Cover if I already have medical aid?
Many specialists charge above medical scheme rates (e.g. 200%–500%). Medical aids often pay at 100%–200% of their tariff, leaving a shortfall. Gap Cover helps cover that difference.
3. Is Gap Cover a replacement for medical aid?
No. Gap Cover is not a substitute for medical aid. You must have an active medical aid scheme to qualify.
4. Is Gap Cover regulated?
Yes. It is regulated under short-term insurance legislation and subject to specific product design limits set by regulation.
5. Does Gap Cover cover day-to-day medical expenses?
No. It is primarily designed for in-hospital shortfalls and certain defined medical events.
6. What does Gap Cover typically pay for?
Depending on the policy:
Specialist shortfalls in hospital
Co-payments imposed by medical schemes
Deductibles on hospital procedures
Sub-limit shortfalls (e.g. internal prostheses)
Oncology shortfalls
Casualty/emergency room benefits
MRI/CT scan co-payments
7. Is there a maximum annual benefit?
Yes. Regulations limit the annual benefit per insured person per year (subject to legislative caps).
8. Does it cover procedures done out of hospital?
Generally no, unless specifically stated (e.g. defined procedures in day clinics).
9. Are co-payments covered?
Many plans cover co-payments for procedures, scans, or hospital admissions, subject to limits.
10. Does Gap Cover cover cancer treatment shortfalls?
Some plans provide oncology gap cover, subject to limits and pre-authorisation.
11. Does it cover internal prostheses?
Certain policies cover prosthesis shortfalls where the medical aid has sub-limits.
12. Are maternity shortfalls covered?
Specialist shortfalls for in-hospital maternity may be covered, but this depends on the plan and waiting periods.
13. Does it cover PMB shortfalls?
Yes, many policies specifically cover shortfalls on Prescribed Minimum Benefits when specialists charge above scheme rates.
14. Who qualifies for Gap Cover?
Anyone who is an active member of a registered South African medical aid scheme.
15. Are there age limits?
Some insurers apply entry age limits or premium adjustments for older members.
16. Is there medical underwriting?
Most Gap Cover products have simplified underwriting but may impose:
General waiting periods
Condition-specific waiting periods
Maternity waiting periods
17. What are typical waiting periods?
Common examples:
3-month general waiting period
6–12 months for pre-existing conditions
9–12 months for maternity
18. Can I switch Gap Cover providers?
Yes, but waiting periods may apply again unless waived under specific conditions.
19. Can my application be declined?
In some cases, yes — particularly if underwriting disclosures indicate high risk.
20. How does Gap Cover work in practice?
The hospital or specialist claims from your medical aid.
Your medical aid pays its portion.
The remaining shortfall is submitted to your Gap insurer.
21. Do I need pre-authorisation?
Some benefits require pre-authorisation, especially for co-payments or specialised procedures.
22. Who submits the claim?
Usually the member submits:
Medical aid statement
Specialist invoice
Proof of payment (if applicable)
23. When must claims be submitted?
Within the timeframe stated in the policy (often 3–6 months from treatment).
24. Can I use any hospital?
Yes, provided it is recognised by your medical aid and the procedure qualifies under the Gap policy terms.
25. What does Gap Cover cost?
Premiums are usually per family per month and are more affordable than medical aid contributions.
26. Does Gap Cover qualify for medical tax credits?
No. Gap Cover premiums do not qualify for medical scheme tax credits.
27. Are premiums risk-rated?
Some policies have flat family premiums; others may increase with age bands.
28. Can premiums increase annually?
Yes. Premiums typically increase once a year.
29. Can I cancel at any time?
Yes, subject to notice periods outlined in the policy.
30. What happens if my medical aid lapses?
Your Gap Cover will not respond to claims without an active medical aid scheme.
31. How long does it take to process a claim?
Processing times vary but are generally a few working days once documents are complete.
32. What documents are required?
Typically:
Medical aid claims statement
Detailed specialist invoice
Proof of payment (if paid upfront)
Hospital account (if relevant)
33. What if my claim is rejected?
You will receive written reasons. You may:
Submit additional documents
Lodge an internal dispute
34. Can I escalate a complaint?
Yes. If unresolved internally, you may approach:
The insurer’s complaints department
The FAIS Ombud
The relevant Short-Term Insurance Ombudsman
35. Are there benefit limits per event?
Yes. Some benefits have event-based caps (e.g. co-payment limits per procedure).
