Gap cover explained
Gap cover is an insurance policy that pays the difference between what specialists charge in hospital and what your medical scheme pays.
The gap it covers
Medical schemes pay specialists, anaesthetists and other doctors at the scheme’s own rate, often 100% to 300% of a scheme tariff. Many specialists charge more than that. The difference, called a shortfall, is yours to pay unless you have gap cover. It can run to tens of thousands of rand for an operation.
What gap cover usually pays
- Shortfalls on specialist and anaesthetist fees for treatment in hospital, and for some procedures done outside hospital.
- Co-payments your scheme charges for certain procedures or for using a hospital outside its network, on many policies.
- Some policies add extras such as cover for cancer treatment shortfalls or the cost of your premiums for a while if the main member dies.
What it does not do
Gap cover is not a medical scheme and cannot replace one. You must belong to a medical scheme to take it out, and it only pays once your scheme has paid its part. It does not cover day-to-day costs such as GP visits or chronic medicine, and it pays nothing towards a claim your scheme rejects.
Limits and waiting periods
Gap cover is sold by insurers under regulations that cap how much a policy may pay per person each year; National Treasury adjusts the cap annually. Policies usually have a general waiting period of a few months and a longer one, often 12 months, for conditions you already had. Check the schedule for the annual limit, the waiting periods and the list of exclusions before you sign.
Who it suits
Gap cover is most useful if you are on a hospital or lower-cost plan that pays specialists at 100% of the scheme rate, if you are planning a procedure after the waiting period, or if you have a family with young children. On top-tier plans that already pay specialists at high multiples, the benefit is smaller.
Frequently asked questions
How much does gap cover cost?
Premiums depend on the insurer, the cover level and your age. Compare several quotes, and compare the annual limit and the exclusions, not only the price.
Can I get gap cover without a medical scheme?
No. Gap cover only pays shortfalls after a medical scheme claim, so you must be a medical scheme member.
Does gap cover pay for a claim my medical scheme rejects?
No. If your scheme does not pay for the treatment, gap cover usually does not pay either.
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Open calculator →Gap cover is health insurance sold under the demarcation regulations to the Long-term and Short-term Insurance Acts; the Minister of Finance approves a CPI-linked escalation of the benefit caps each year, most recently on 1 September 2026 (gov.za; Acts Online). Checked 18 October 2026. General information, not financial advice; the policy wording of each insurer applies.