The Complete List of Gap Cover Providers in South Africa

Gap cover is becoming increasingly necessary among South Africans who belong to a medical aid. Soaring medical costs mean that medical aids do not always cover the full costs of consultations.

Consequently, many South Africans are turning to gap cover products. Most medical aids set an MST (medical scheme tariff) which is the amount they are prepared for the services of private healthcare professionals. However, the actual rates may differ.

Enter gap cover, which covers the deficit between the rate charged and the MST your medical aid pays. Most medical aids pay the healthcare providers 100% of the scheme rate. Some go as far as paying 200-300% of the rate. But the shortage of medical healthcare professionals allows them to charge rates of up to 500% of the MST.

How does gap cover work?

  • You can use gap cover to make the expensive co-payments that most medical aid members have to pay at private hospitals. Co-payments can include money for the hospital admission and the bed as well as some surgical procedures. Most medical aids have mandatory cop-payments in place for when members use a hospital that isn’t in the scheme’s preferred network.
  • Gap cover plans can pay out a lump sum for the treatment of specified conditions. These include visits to a casualty ward, certain cancers, internal prostheses such as joint replacements and some dentistry procedures.

Anyone who is a member of a registered medical aid as well their dependants are eligible for gap cover. To qualify for some gap cover plans, you have to be 60 years old and under. Children are covered up to a specified age. To qualify, all those covered must be on the same medical aid and plan.

Some exclusions apply:

  • There is a waiting period of three months before the cover becomes effective.
  • For pre-existing conditions, there is a 12-month waiting period.
  • Gap cover plans do not cover all procedures. The products and what they include or exclude vary. However, most plans exclude cosmetic surgery, specialised dentistry and treatment for obesity.
  • If you do not claim within six months of treatment, your gap cover provider will refuse to pay.
  • Medical aid members who incur co-payments for failing to follow the medical aid’s policies like those that govern hospital admissions cannot claim these amounts.
  • Cover extends to a specified amount beyond which you cannot claim. Providers offer a variety of products with different limits to suit your budget.

Which companies offer gap cover plans?

  • Zestlife
  • Stratum
  • Turnberry
  • Essential gap cover
  • Ambledown
  • Complimed gap cover
  • Xeulus
  • Sirago
  • Jenius
  • Talksure
  • Old Mutual
  • Elixi
  • ABSA
  • Sanlam
  • Discovery

Before deciding on which provider to use, speak to a financial advisor, or compare quotes online.

What are the factors to consider?

  • The amount of cover you need for you and your family.
  • The monthly premium and whether or not you can afford it.
  • The conditions that the gap cover includes and excludes.
  • The reputation and track record of the gap cover provider.

The reality is that most South Africans cannot afford to pay the difference in price between what they are charged and what their medical aids will pay. That’s why the gap cover market is growing. At this stage, it covers only a fraction of medical aid members. As it becomes more apparent that gap cover is a necessity, more South Africans will make it part of their monthly budget.