GAP cover (also called medical gap insurance) is an additional insurance product that you buy separately from your medical aid.
Its purpose is to cover the shortfall when a doctor or specialist charges more than what your medical aid is willing to pay.
- What GAP Cover Is
- GAP cover is not a medical aid.
- It is an insurance policy that helps you pay the difference between:
- what your specialist charges, and
- what your medical aid pays from your hospital benefit.
Typical example:
A neurologist charges 300% of medical aid rate, but your medical aid pays only 100%. GAP cover helps pay the extra 200%.
- What GAP Cover Does Cover
Most GAP cover plans pay for:
- Hospital specialist shortfalls (consultants, surgeons, anaesthetists).
- In-hospital procedures where the claim exceeds medical aid rates.
- Certain co-payments, depending on your plan.
- MRI / CT scan co-payments (some plans).
- Emergency or trauma benefits (varies by provider).
- Deductibles for certain procedures.
Important: GAP cover is mainly designed for hospital-related costs and not every day chronic care.
- Will GAP Cover Pay for Treatment Co-Payments?
Sometimes yes — sometimes no.
It depends entirely on the specific GAP plan.
Usually Covered:
✔ Hospital admission co-payments
✔ MRI/CT co-payments (depending on the plan)
✔ Specialist shortfalls (in-hospital)
Usually Not Covered:
✖ Chronic medication co-payments
✖ Day-to-day expenses
✖ Consultations outside hospital (unless explicitly stated)
For MS treatments:
Most GAP covers do NOT pay co-payments for disease-modifying therapy (DMT) unless the plan specifically says it does — and most do not.
Always check the benefit wording.
- Can GAP Cover Be Depleted?
Yes.
GAP cover has annual limits, which can run out.
Typical limits include:
- Overall annual limit (e.g., R150,000 – R200,000 per insured person per year).
- Internal limits for scans, co-payments, or oncology.
- Some benefits are capped per claim or per event.
Once the annual limit is reached, GAP cover will not pay further claims for that year.
- Key Things Patients Should Know
- You must already have a medical aid to take out GAP cover.
- GAP cover does not replace medical aid or cover what your medical aid excludes.
- Pre-existing condition waiting periods may apply (usually 10–12 months).
- Claims are usually submitted after your medical aid processes the bill.
- Simple Summary for Quick Messaging
GAP cover helps pay the difference when specialists charge more than your medical aid covers, mainly during hospital procedures. It may pay some co-payments (like MRI scans), but it usually does not cover chronic medication co-payments. It has annual limits, so it can be depleted. Always check the specific plan’s benefits.