Many people who have a basic hospital plan and gap cover on top of that think they are completely covered. Not entirely true.

Gap cover is designed to pay the ‘gap’ or shortfall between what your medical scheme pays, and what a private doctor charges.

If your medical scheme tariff or a specialist visit is R600 (in-hospital) and the bill is R1 100, the gap cover is supposed to foot the total bill for the difference of R500 – or so people think.

Gap cover usually requires only one policy for a single, (member/any dependents), so it is still a very good deal if you have several dependents. In, essence, you actually, just pay once, and you are all covered, provided you and your dependents are all on the same scheme and on the same option.

Things most gap cover policies exclude payment for:

  • Ward costs in a hospital or step-down facility;
  • Upgrades to a private room;
  • Pre-admission consultation costs;
  • Medication (both in-hospital and take-home);
  • External prostheses (an artificial breast or a prosthetic leg);
  • External appliances, such as wheelchairs or crutches;
  • Routine medical examinations, such as ultrasounds;
  • Home or private nursing;
  • Extra costs related to weight/BMI-related procedures;
  • Mental health disorders, transportation costs (such as in an ambulance);
  • Out-of-hospital dental treatments;
  • Cosmetic procedures;
  • Costs incurred for treatment by a non-designated service provider (determined by your medical scheme); and
  • Co-payments for any procedure for which you are in a waiting period.

Some pleasant surprises in what gap cover might include payment for:

Again, this depends solely on your insurance provider and the policy you have chosen (there is usually a choice between two: the no-frills version and the more comprehensive one). It can do no harm to check and even if the amount is not huge, every little bit helps. You might find that your gap cover could pay for some of the following:

  • Some out-of-hospital procedures that used to be require hospitalisation, but can now be performed in a doctor’s surgery. Contact your insurer for details on these.
  • Co-payments for certain specified hospital procedures (in full). Call your insurer for details.
  • A contribution to cancer treatment costs once your cancer benefit on your medical scheme has run out.
  • The shortfall on internal prostheses (such as a hip replacement procedure) up to a stipulated maximum.
  • A lump sum for first-time cancer diagnosis (terms and conditions usually apply).
  • Lump sum benefit for accidental death or permanent total disability.
  • Lump sum for long-term hospitalisation over a certain period, of time.
  • Tooth repairs in the case of accidental injury (such as breaking a tooth in a car accident).
  • Some casualty costs (once again, terms and conditions apply).


For Answers and questions

  1.  How do I know which benefit option to select?

Ensure that you understand how the benefit options operate and elect, the benefit to suite your healthcare needs and what you can afford. A good broker will alert you to the options that are best suited to your needs. It is essential that you obtain the rules of the scheme or a summary thereof to verify all information relevant to enable you to make an informed choice.

  1. Can I belong to more than one medical scheme at the same time?

No. It is illegal.

  1. What does a waiting period mean?

Schemes can apply waiting periods because you have never belonged to a medical scheme or you have had a break in membership of more than 90 days before joining a medical scheme. You will not have cover or access to the prescribed minimum benefits during your waiting periods. This includes cover for emergency admissions.

  1. What are Prescribed Minimum Benefits (PMB)

In terms of the Medical Schemes Act of 1998 (Act number 131 of 1998) and its regulations, all medical schemes have, to cover the costs related to the diagnosis, treatment and care of:

  • any life-threatening emergency medical condition
  • a defined set of 270 diagnoses and
  • 27 chronic conditions.

These conditions and their treatments are known as the Prescribed Minimum Benefits (PMB).

All medical schemes in South Africa have, to include the Prescribed Minimum Benefits in the health plans they offer to their members. There are, however, certain requirements that a member must meet before he or she can benefit from the Prescribed Minimum Benefits.

The three requirements are:

  1. The condition must be part of the list of defined PMB conditions
  2. The treatment needed must match the treatments in the defined benefits on the PMB list
  3.  Members must use the scheme’s designated healthcare service providers.


  1. What is the difference between a benefit and a limit?

A benefit is a pool of funds in a medical scheme reserved for specific healthcare services. For example, the Hospital Benefit pays for healthcare services when you are admitted to hospital as part of an approved admission.

A limit is the maximum amount or a cap on what we will pay for a particular, type of healthcare service. This applies when the service is paid from a specific benefit. For example, your optometry claims either pay from the Medical Savings Account or Above Threshold Benefit but we will only pay these claims up to the optometry limit for your health plan.