Benefits of Gap Medical Aid Insurance Cover

Do you know what GAP cover insurance is and how it can benefit you with regards to medical aid payment shortfalls?

When hospitalized, you are usually in for a very expensive event, and you will hope that your medical scheme will pick up the costs. Very often, this is not the case and one is left with a VERY significant money shortfall that has to come out of your own pocket. This can amount to many thousands of Rands, and in some cases, up to as much as R40,000.

Your gap cover policy arranges to provide a refund to you for just such an eventuality.

 Gap Medical Aid Insurance


  • Everything hinges around the NHRPL- this stands for “National Health Reference Price List”.
  • The NHRPL is a list which includes operations, procedures,diagnostics and the like across the broad spectrum of medical disciplines with a “price tag”next to each. This “price tag” is the recommended medical aid rate for that operation or procedure.
  • When you are hospitalized you will get an account from the hospital (this will include accommodation, theatre fees, medicines) as well as accounts from the practitioners (surgeon, anaesthetist, physician, physiotherapist,etc).
  • You will find that the hospital account (which is excluded from the GAP cover) will be paid pretty much in full by your medical scheme but that there could likely be a LARGE shortfall in the payment they give you against the accounts of the practitioners. This shortfall or GAP is then going to be the subject of a refund to you from the GAP POLICY and which you will be very happy and relieved to get.
  • It is necessary to be a member of a registered medical scheme to obtain the benefit of a GAP policy and this policy will essentially cover all your dependants registered under your medical scheme policy.
  • Of course there are limits to the benefits but they are very generous anyway, as much as R100 000 per annum for each beneficiary and R200 000 per annum for the membership as a whole,  limited to the equivalent of 300% of the NHRPL amount.
  • There are certain circumstances under which there will be no benefit due, such as procedures for which no benefit is paid from the medical scheme, attempted suicide, drug taking or conditions for which the person received medical advice during the 12 months prior to becoming a GAP member or during any waiting period under the plan.
  • Benefits include cover for chemotherapy, radiotherapy and kidney dialysis.
  • There is no age limit for membership, but you must be under 65 years of  age when you join.

It’s all that simple, and only for R90 per month, you can get GAP cover whether you are a single member without dependants, or a family. Employer groups of 10 plus can negotiate lower rates.