Most Gap Cover policies provide benefits for a policyholder and their spouse and those financially dependent on them (child/children and/or aged parents) who are covered on one policy of a registered medical aid scheme. Members and their dependants can also be on two different medical aids and one Gap Cover Policy but only if they are legally married, or common law partners verified by submission of an affidavit confirming 12 months of cohabitation. There is often no entry age limit.

Gap cover is used to cover shortfalls when doctors charge above medical aid rates. Gap cover is designed to provide extra protection for those who already have a medical aid. If a procedure or medical expense is covered in full by your medical aid or if your treatment is excluded by your medical aid, then gap cover will not cover the excess costs.

Gap cover is not just valid for hospitalisation. Gap cover covers shortfalls where doctors charge above the medical aid rate for certain procedures performed in the doctor’s rooms – but they have to have been authorised and paid for from the In-Hospital or Major Medical Benefit first.

Gap Cover is not a medical aid and the cover is not the same as that of a medical aid scheme. The cover is not a substitute for a medical scheme membership.

Gap Cover will cover the shortfall that arises after your medical aid has processed your account and is due to service providers charging above scheme tariff for authorised in-hospital procedures. The cover is limited to a percentage of the original scheme tariff.

When are you not covered under your Gap Cover policy?

Where your medical aid does not pay their portion of an account first from the Risk or Major Medical benefit. No claims processed from your Scheme’s day to day benefit will be covered – except for the Casualty benefit. (Please check your option benefits in the Schedule).