What is Gap Cover?

Gap Cover is a stand-alone short term insurance product and is not linked to a specific medical scheme.

The main benefits of Gap Cover products (depending what Gap Cover product you join) are:

  • Paying the difference in cost on the specialist and anaesthetists accounts for procedures performed in Hospital or Day Clinic theatres up to a specific percentage (300%, 400%, 500% or 600%).
  • Co-payments on specific procedures and benefits like MRI & CT scans, Endoscopic procedures etc.
  • Death and Disability cover.
  • Oncology Cover
  • Prosthesis Benefit

A typical example for in Hospital procedures would be the following:

You go for a shoulder operation in Hospital and the specialist charges you 300% (R30 000) to perform the procedure. His anaesthetist also charges you 300% (R3 000), but your medical scheme only covers Hospital events and treatment at the normal medical scheme tariff / rate, which is 100%.
The scheme will thus only pay R10 000 towards the specialists account and R1 000 towards the anaesthetists account. The balance of R20 000 and R2 000 respectively will be for your own account. These are the amounts you will now claim from GapCover.


An example of co-payments would be the following:

You need to go for a MRI scan out of Hospital at the radiologists, but there is a co-payment of R1 500 per MRI scan on your benefit option. You will first pay the R1 500 to the radiologists and then claim it back from GapCover.


How do I claim from Gap Cover and what do I need?

A Gap Cover claim can only be submitted once the medical scheme has paid there portion of the account. Once that has been done, the balance can be claimed from Gap Cover by submitting the following documents:


  • Completed Gap Cover Claims Form
  • Copy of the account(s) you are claiming for.
  • Copy of the Hospital account – you will need to contact the Hospital and request that they e-mail you a copy.
  • Medical Scheme Statement – showing what portion they have paid.
  • Proof of payment – only applicable to co-payments.

Gap Cover does not pay the service providers, because they pay the money into your bank account and you then pay the service providers.


Why is it important to have Gap Cover?

Most service providers (specialists and anaesthetists) charge more than the normal medical scheme tariff / rate (100%). Most medical schemes however now have a network of service providers which members can make use of, and where there will be no shortfall in payment.
The problem arises however when you do not want to make use of their service providers but rather a provider of your choice.

The other big challenge is planned PMB procedures. If you do not use one of the medical schemes designated service providers for a planned PMB procedure, you cannot claim the difference in costs from many of the Gap Cover products / providers.

It is therefore VERY important that you first confirm if your Gap Cover policy covers PMB procedures, because almost 53% of all Hospital admissions are PMB’s.