Last reviewed: August 2026. We review our guides regularly to keep them accurate.
By Martin Janse van Rensburg, Sales Manager and Financial Advisor at Curemed. Reviewed by Roxanne Hurter-Ehlers, Director of People and Governance.
On the Curemed book, Gap Cover pays. Curemed members claimed R10,520,751 in medical shortfalls in the first six months of 2026, and R40.32 million since inception across roughly 21,000 claims.
Those are not illustrative figures. They come from the Curemed broker dashboard administered by Total Risk Administrators, refreshed to end June 2026, so every rand below was paid to a real member with a real hospital account.
What follows is where that money went, which specialities produce the biggest shortfalls, and why a small share of claims do not pay. It is the closest thing to an honest answer to the question of whether Gap Cover earns its premium.
In short
- R10,520,751 was paid to Curemed members in the first six months of 2026.
- R40.32 million has been paid since inception, across roughly 21,000 claims.
- The largest benefit line to date is Overall Annual Limit top-ups at R17.95 million, and R12.87 million of that went to shortfalls on Prescribed Minimum Benefit claims.
- Cardiology produces the biggest average shortfall per claim at R7,195, followed by medicines at R5,807.
- 1,509 members received a payout in the first half of 2026 alone.
- Most declined claims are process issues, not gaps in cover, and the two biggest reasons both involve Prescribed Minimum Benefits.
How much has Curemed Gap Cover paid out to members?
The table below is the headline claims record. The 2026 figure covers January to June only, because the dashboard is refreshed to end June 2026.
| Period | Total claims paid |
|---|---|
| 2026 year to date (January to June) | R10,520,751 |
| 2025 (full year) | R16,142,838 |
| 2024 (full year) | R13,654,107 |
| Since inception (all years) | R40.32 million across roughly 21,000 claims |
Curemed broker dashboard figures, administered by Total Risk Administrators, refreshed to end June 2026.
Read the run rate rather than the raw total. Almost R10.5 million went back to members in six months, which puts 2026 ahead of the 2025 full year figure of R16,142,838 on an annualised basis. Claims volumes on this book are rising, not flattening.
What is Gap Cover actually paying for?
The benefit line breakdown to date shows where the value sits. Note that these lines are not mutually exclusive, because Prescribed Minimum Benefit shortfalls sit inside the Overall Annual Limit spend, so they should not be added together.
| Benefit line | Paid to date |
|---|---|
| Overall Annual Limit top-ups | R17.95 million |
| Prescribed Minimum Benefit shortfalls (about 72% of the annual limit spend) | R12.87 million |
| Co-payments and designated service provider penalties | R3.47 million |
| Dental benefit | R1.04 million |
| MRI and CT scan co-payments | R800,000 |
| Prostheses sub-limits | R779,000 |
| Oncology benefits (extender, gap and new technology combined) | R622,000 |
| Casualty benefit | R456,000 |
Curemed broker dashboard benefit line totals to date, administered by Total Risk Administrators.
The R12.87 million figure is the one worth pausing on. Under Regulation 8(1) of the Medical Schemes Act regulations, a scheme must pay the Prescribed Minimum Benefits in full, without co-payment or deductibles, when you use the designated service providers. In practice, PMB claims still leave shortfalls, and on this book those shortfalls account for roughly 72% of the Overall Annual Limit spend.
That is the strongest argument in the data. Members who assumed the legal minimum protects them from every rand of a hospital account were the ones claiming most.
Which specialities leave the biggest shortfalls?
Average amount paid per claim in the first half of 2026, by discipline.
| Discipline | Average paid per claim |
|---|---|
| Cardiology | R7,195 |
| Medicines | R5,807 |
| Maxillofacial and oral surgery | R5,126 |
| Hospital | R4,413 |
| Neurosurgery | R4,233 |
| Gynaecology | R4,059 |
Average paid per claim, 2026 year to date, Curemed broker dashboard.
Cardiology and specialist surgery produce the bill shocks, which fits how these accounts are built. A cardiac admission brings a cardiologist, an anaesthetist, a physician and often a surgeon, and each one can charge above the scheme rate on the same event.
Who is claiming, and on which Gap Cover products?
Across 2024 to 2026, 5,861 members joined. In the first half of 2026 alone, 1,509 distinct members received a payout, so claiming is routine rather than rare.
Product mix is led by CureMed Super Cover Plus at 54%, followed by Basic 300 at 14%, Absolute Cover Plus at 13% and Vital Cover Plus at 13%. Members span every age band from the twenties through the nineties, with the strongest concentration between ages 30 and 59, which is the stage where family cover, surgery and chronic care tend to overlap.
Why do some Gap Cover claims get declined?
Being straight about this is more useful than quoting a payout rate. The most common reasons a claim does not pay are below.
| Reason a claim does not pay | Share of declines |
|---|---|
| Possible Prescribed Minimum Benefit, query with the medical aid first | 21% |
| Shortfall on a Prescribed Minimum Benefit claim already paid by the medical aid | 17% |
| Claim correction required | 10% |
| Claim already fully covered by the medical aid | 7% |
| Claimed amount under R100 | 5% |
| Duplicate claim | 4% |
Top reasons claims are declined, Curemed broker dashboard.
Read that list again and a pattern appears. These are mostly sequencing and paperwork issues rather than gaps in cover. The two largest reasons, at 21% and 17%, both involve Prescribed Minimum Benefits, where the scheme carries a legal duty to pay in full, so the claim goes back to the medical aid before Gap Cover considers a shortfall.
The practical lesson for members is simple. Send the account to the medical scheme first, wait for the scheme to settle its portion, then submit the remaining shortfall with the full statement attached. A Curemed Advisor can run that sequence with you.
How much can one insured person claim in a year?
Gap Cover is regulated as short-term insurance under the Demarcation Regulations rather than the Medical Schemes Act, and it carries an annual limit per insured person. The base amount in the Regulations is R150,000 per insured person a year, escalating annually in line with inflation.
The latest officially published escalated limit is R219,845.96 per insured person a year, effective 1 April 2025. No 2026 escalation had been published by National Treasury or the FSCA as at August 2026. Individual policies may set their own limits at or below the regulated maximum, so check the schedule for the specific product.
So is Gap Cover worth it for you?
The claims record answers whether Gap Cover pays. Whether it suits you is a different question, and it depends on your scheme, your plan, your health and your budget.
Two things to be clear about. Gap Cover is not a medical scheme and is not a substitute for one, so it requires active medical scheme membership to pay. It also does not cover day-to-day costs such as routine GP visits, dentistry outside the specific dental benefit, or optometry. It sits behind your scheme for mainly in-hospital events.
The case is strongest where your plan carries known co-payments or a restricted network, which is common on entry level options. If you are weighing up cover at the lower end of the market, our guide to medical aid under R1,500 in South Africa sets out the co-payment rules on those plans, and the complete Gap Cover guide for South Africa explains the product in full. For the wider picture, see how much medical aid costs in South Africa.
Curemed is an independent, FSCA-licensed brokerage, FSP 44098, established in 1992 and serving all nine provinces. Because we are not tied to one provider, a Curemed Advisor can compare Gap Cover options against the plan you actually have, at no cost to you.
Speak to a Curemed Advisor about Gap Cover
Frequently asked questions
Do I need a medical aid to take out Gap Cover?
Yes. Gap Cover is the one category of health policy that may require the policyholder to belong to a medical scheme, and it is designed to top up what your scheme does not pay in full. Without active medical scheme membership there is no scheme settlement to measure a shortfall against, so there is nothing for the policy to pay.
Does Gap Cover pay for day-to-day costs such as GP visits or spectacles?
No. Gap Cover is built for mainly in-hospital events and the shortfalls attached to them. Routine GP consultations, optometry and general day-to-day expenses fall outside it, and belong to your medical scheme day-to-day benefits or your own pocket. The dental and casualty benefits shown above are specific defined benefits, not general day-to-day cover.
How soon after taking out Gap Cover can I claim?
Gap Cover waiting periods are limited to 3 months general and 12 months condition-specific. Where you held a materially similar policy before, waiting periods you already completed on that policy are recognised, so tell your Advisor about prior cover rather than starting from scratch.
Is there a minimum amount before a claim is worth submitting?
In practice, yes. Claims under R100 made up 5% of all declines on this book, so very small shortfalls are unlikely to pay. Submit the full account rather than a single line item, because several shortfalls attached to one admission are usually assessed together.
Can I keep Gap Cover if I change medical scheme or plan?
Gap Cover requires active medical scheme membership, so tell your Advisor whenever you move scheme or change plan. The shortfall you face depends on the reimbursement rate and co-payment rules of the plan you are on, so a plan change can alter what your Gap Cover needs to absorb even though the policy itself continues.
Martin Janse van Rensburg
Sales Manager and Financial Advisor | Curemed Health and Wealth Consultants
More about MartinFigures shown are aggregated Curemed member Gap Cover claims from the Curemed broker dashboard administered by Total Risk Administrators, refreshed to end June 2026. Individual claims, benefits and limits vary and are subject to the terms, conditions and qualifying criteria of your Gap Cover policy. Gap Cover is a short-term insurance product and is not a medical scheme, and it is not a substitute for medical scheme membership. This article is for information purposes only and is not financial advice. Curemed is a licensed financial service provider with the FSCA, FSP 44098.