Last reviewed: July 2026. We review our guides regularly to keep them accurate.
In short
- Gap cover is short-term insurance that pays the shortfall between what your medical scheme pays for in-hospital specialists and what they actually charge.
- It is not a medical aid and cannot replace one. You must belong to a medical scheme for gap cover to work.
- It is regulated as insurance under the demarcation regulations, in effect since 1 April 2017, not the Medical Schemes Act.
- It typically covers in-hospital shortfalls, co-payments and certain sub-limit top-ups, not day-to-day costs.
- Benefits and limits differ between insurers, so always read the policy schedule.
By Martin Janse van Rensburg, Sales Manager and Financial Advisor · Reviewed by Roxanne Hurter-Ehlers
Gap Cover is one of the most misunderstood products in South African healthcare. In short, it is an insurance policy that pays the difference between what your medical aid covers in hospital and what your specialists actually charge. It is not medical aid, and it cannot replace it. This guide explains what Gap Cover is, why the shortfall happens, what these policies do and do not cover, and how to choose one, written by an FSCA-registered broker (FSP 44098).
What is Gap Cover?
Gap Cover is a short-term insurance product that tops up your medical aid. When you are treated in hospital, your medical scheme pays specialists at a set rate, usually called the scheme rate or medical scheme tariff. Many specialists, such as anaesthetists, surgeons and radiologists, charge more than that rate, sometimes several times more. Your scheme pays its portion and you are left with the difference. Gap Cover is designed to pay that difference, so you are not out of pocket for a shortfall you did not expect.
Gap Cover sits alongside your medical aid. You must have a medical scheme for a Gap Cover policy to work, because Gap Cover only pays in relation to a claim your scheme has already assessed. It is regulated as insurance by the Financial Sector Conduct Authority under the demarcation regulations that took effect on 1 April 2017, which is a different framework to the one that governs medical schemes.
Why does the shortfall happen?
Medical schemes reimburse in-hospital specialists at their scheme rate. Specialists are not obliged to charge that rate, and many bill at 200 percent, 300 percent or more of it, especially for complex procedures. The portion above what your scheme pays is the shortfall. On a large hospital account, that gap can run into tens of thousands of rand. Gap Cover exists precisely because this gap is common, unpredictable and can be very large.
What Gap Cover typically covers
| Benefit | What it does |
|---|---|
| In-hospital shortfall cover | Pays the difference between the scheme rate and what in-hospital specialists charge. This is the core benefit. |
| Co-payment and deductible cover | Refunds fixed co-payments or deductibles your scheme applies to certain procedures, scopes or scans. |
| Sub-limit cover | Tops up procedures your scheme covers only up to a set amount, such as certain prostheses or scopes. |
| Casualty or emergency cover | Helps with emergency-room visits that do not lead to admission, which schemes often pay from day-to-day benefits or not at all. |
| Cancer and other sub-limit boosts | Some policies extend cover for oncology shortfalls or specific treatment sub-limits. Benefits vary by policy. |
Exact benefits, sub-limits and waiting periods differ between providers and policies. Always read the policy schedule.
What Gap Cover does not do
Gap Cover has clear limits, and understanding them prevents nasty surprises:
- It is not medical aid. It cannot be your only cover. You need a registered medical scheme underneath it.
- It is capped. The demarcation regulations set an annual limit per insured person, which is adjusted each year. Very large shortfalls can exceed it.
- It mostly relates to in-hospital events. It is not a day-to-day benefit and will not pay for routine GP, dental or optical visits.
- Waiting periods and exclusions apply. New policies usually have general and condition-specific waiting periods, and pre-existing conditions may be excluded for a time.
Who needs Gap Cover?
Gap Cover is worth serious consideration for almost anyone on a medical aid who could face in-hospital specialist bills, but it is especially valuable if you use private specialists who charge above scheme rates, if you are planning a procedure such as surgery or childbirth, if you have a family where the odds of a hospital event are higher, or if your plan has co-payments or sub-limits on common procedures. For a relatively small monthly premium, it removes the risk of a large, unexpected shortfall on an otherwise covered hospital stay.
For a real-world view of what Gap Cover pays, see the R1.5 million in Gap Cover claims Curemed paid to clients in 2026.
How to choose a Gap Cover policy
When comparing policies, look beyond the premium and check:
- The percentage of scheme rate it covers shortfalls up to (for example 500 percent of the scheme rate).
- Whether it covers co-payments, deductibles and sub-limits, not just specialist shortfalls.
- The waiting periods and how pre-existing conditions are treated.
- Whether casualty, oncology and sub-limit boosts are included.
- Any age limits or premium increases as you get older.
- That it is offered by a licensed insurer and sold by an FSCA-registered Advisor.
The right policy depends on your medical aid plan and your circumstances, which is why we run a needs analysis before recommending one. To understand how Gap Cover differs from a medical scheme in the first place, see our guide on medical aid versus health insurance.
Frequently asked questions
Is Gap Cover the same as medical aid?
No. Medical aid is a registered medical scheme that pays your medical costs and must cover Prescribed Minimum Benefits. Gap Cover is a separate insurance product that only tops up specialist shortfalls and certain co-payments on an existing medical aid. You cannot have Gap Cover without a medical scheme.
How much does Gap Cover cost?
Premiums depend on the provider, the benefits and your family size, and they change each year, so we do not quote a fixed figure here. Gap Cover is generally a small fraction of a medical aid contribution. Ask us for a current quote based on your plan.
Is there a limit to what Gap Cover pays?
Yes. The demarcation regulations set an annual limit per insured person, adjusted each year. Most claims fall well within it, but very large shortfalls can exceed the cap, which is one reason to choose an appropriate medical aid plan as your base.
Are there waiting periods on Gap Cover?
Usually yes. New policies typically apply a general waiting period and longer waiting periods for specific conditions, and may exclude pre-existing conditions for a time. Check the policy schedule before you rely on it for a planned procedure.
Want Gap Cover matched to your medical aid plan?
Speak to an independent brokerLast updated: 8 June 2026. General information, not advice. Gap Cover benefits and the regulated annual limit change over time. A personalised recommendation follows a written needs analysis under the FAIS Act.
Martin Janse van Rensburg
Sales Manager and Financial Advisor | Financial Advisor specialising in medical aid
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