Complete guide to Medical Gap Cover Insurance in 2022

A medical gap cover is important to have, considering the private hospital’s charges and costs. With a medical gap cover, you will not need to worry about the access amount on your medical aid that specialist doctors charge.

Medical gap cover grew in popularity in South Africa at the beginning of the last decade. Specialist doctors can charge 500% or more than what medical schemes cover for you. Due to this fact, many are opting to take a medical gap cover to encompass that extra amount that specialist doctors charge.

Considering that medical gap cover is expensive, you can gain tremendously should you get hospitalized. Some medical gap covers can pay in hundreds of thousands per annum for shortfalls.

What is a medical gap cover?

A medical gap cover is a short-term insurance product that provides insurance for medical scheme holders and covers a deficit between your medical scheme tariff and the actual costs from a private specialist doctor.

As much as the definition is lengthy it is, however, easy to understand. For example, if your private hospital bill comes back as R2000 and your medical aid only covers R1200 of your bill, then your medical gap cover will pay the R800 difference.

What you need to know is that a medical gap cover also has its own limitations just as a medical aid does. These limitations will vary depending on the type of medial scheme you have.

Medical gap cover limitations

The cover has some limitations and these are important to know as they will determine your benefit. Here are the most common limitations that come with the medical gap cover.

1. Maximum annual limit

With a gap cover, you are allowed what is called an overall annual limit. This is the maximum amount you are covered for per annum and it cannot go further than that. The maximum overall annual limit for 2020 is R165,000.00.

You need to know the maximum annual limit on your medical gap cover. Remember that a specialist doctor can charge a rate way over your medical aid and in some cases by thousands of percentage in increase.

So, you might eventually have to foot some or most of your medical bill yourself.

2. Changes in your medical scheme cover

Medical scheme plans can change over time and these changes can affect your gap cover. Your medical gap cover will only cover what your medical scheme covers. So if your medical scheme changes this will affect your benefits.

Should your medical scheme change, you need to reconsider, whether it still makes sense for you to keep your gap cover. Otherwise, you will get a shock of your life when you want your medical gap cover to pay what your previous medical scheme was covering you.

3. Waiting period

A medical gap cover comes with a waiting period for new policyholders. This is because of pre-existing medical conditions as gap cover providers will want to pay attention to your health.

Before taking a gap cover you need to know the waiting period of your cover. Especially those who suffer from a chronic disease as this might save you a fortune in hospital bills.

What to consider when taking a medical gap cover

Since you now know the limitations of the medical gap cover, it is now the time to look at considerations that you need to make when taking out a gap cover. You don’t have to just shoot out and acquire a gap cover, there are important things that you need to consider beforehand.

Here are the considerations that you need to make before or when taking out a gap cover.

1. Be sure your medical shortfalls will be covered

Be 100% that your medical shortfalls will be covered. You need to seek assurance through your financial advisor that medical shortfalls will be covered owing to the overall annual limit.

2. What happens when you change or downgrade your medical plan

Changes to your medical scheme can affect your medical gap cover. You will need to find out what it entails should you downgrade or upgrade your medical scheme. This will prepare you should you want to take any cause with your medical scheme plan.

3. Whether your gap cover compliments medical scheme

Since the gap cover only covers what your medical scheme covers, you need to be aware of your medical scheme benefits. When you are aware of what your medical scheme covers you can then take a gap cover to suit your needs. Otherwise, you might not even need a gap cover at all if your medical scheme only covers what you deem as less important medical procedures or those that are inexpensive.

4. Understanding limits on your medical gap cover

Know your annual limits on your gap cover and make sure that it makes sense for you. You can do necessary calculations keeping in mind the standard specialist rates and also your medical scheme benefits.

5. Protection of your overall annual limit

Your cover provider should do the right thing by making sure that your annual limit is protected. There are a number of things that your gap cover provider can do, these may include:

  • Negotiating discounts on your medical bill.
  • Do investigations on whether or not should the claims be covered by the medical scheme.


Medical gap cover plays a big role in covering medical bills than you can imagine. This is very true especially for those who have a medical scheme with a number of dependents. Your spouse and children will be able to benefit from a gap cover which will save you money.

A very big advantage is that gap cover normally don’t have any age restrictions and can accommodate anyone regardless of their age. Also owing to the fact that medical schemes are only limited to a rate of 200%, a gap cover will pay 500% of the medical scheme tariff. So there is more to benefit considering that the gap cover is cheaper than the medical scheme in terms of monthly premiums.

Complete guide to Medical Gap Cover Insurance in 2022

Lethabo Ntsoane

Lethabo Ntsoane holds a Bachelors Degree in Accounting from the University of South Africa. He is a Financial Product commentator at Rateweb. He is an expect financial product analyst with years of experience in reviewing products and offering commentary. Lethabo majors in financial news, reviews and financial tips. He can be contacted at [email protected]

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