Gap cover explained: what it pays, what it costs and what to check

Your medical scheme pays specialists and hospitals at its own rate, called the scheme rate or tariff. Many specialists charge more than that. The difference between the bill and what the scheme pays is the shortfall, or "gap", and you are liable for it.

Insurers describe what they pay as a multiple of the scheme rate. Netcare's GapCare pays up to an additional 500% of medical aid tariffs. Sanlam's Gap Cover pays up to an additional six times medical aid rates. Discovery Gap has tiers that pay up to 100%, 250% and 500% of the scheme rate. The wording differs between insurers, so ask exactly how the multiple is calculated before you compare two policies.

Here is the idea in percentages. Say your plan pays a specialist at 100% of the scheme rate and the specialist charges 300%. The shortfall is 200% of the scheme rate. A policy that pays an additional 300% or more covers all of it, subject to the annual limit. A policy that pays only an additional 100% leaves you with half.

Depending on the policy, gap cover can also pay:

• scheme co-payments and deductibles on procedures such as scopes and scans
• sub-limit shortfalls, for example on oncology or internal prosthetics
• some out-of-hospital procedures and casualty visits

Read co-payments and sub-limits to see where those shortfalls come from.

Gap cover is treated as a "medical expense shortfall" contract under the Demarcation Regulations. Those regulations cap what a policy may pay in total, per insured person, per year. The cap started at R150 000 in April 2017 and rises with inflation every 1 April.

Treasury applied the 2025 inflation rate of 3.2% and published the new figure on 1 September 2026, five months after it took effect. Some brochures and web pages still quote last year's amount, and at least one 2026 insurer brochure shows about R219 800. If a policy quotes the older figure, ask the insurer which limit it applies to claims from 1 April 2026. Treasury's own statement is on gov.za.

The limit is a ceiling on everything a policy pays for one person in one year. Individual sub-limits are usually lower.

These are the gap products whose 2026 prices we could verify on the insurer's own pages. Prices are "from" figures for a main member. Your quote depends on your age and the option you pick.

Other gap products are listed without prices because we could not verify their rates. Discovery Gap is for Discovery Health Medical Scheme members other than KeyCare. Zestlife and Stratum Benefits offer 300%, 400% or 500% options. Turnberry's Optimal and Synergy plans pay up to 500% and its Launch plan 350%. Sirago's Gap Core pays 350%, up to a maximum of 450%. Ambledown pays up to six times the scheme tariff, and Admed up to 500%.

There is no single best gap cover in South Africa. The best one closes the shortfall your own plan leaves, at a price you can keep paying. See the gap cover buying checklist.

Gap policies carry their own waiting periods. Sanlam and Old Mutual both state a three-month general waiting period and a 12-month condition-specific waiting period. The general period applies to almost any claim. The longer one applies to conditions you already had.

Gap cover sits outside the Medical Schemes Act, so as we read it the scheme limits on waiting periods (a maximum of three months general and 12 months condition-specific) do not govern the insurer. The policy document does.

People often search for gap cover with no waiting period. We could not verify a policy with no waiting periods at all from the insurers' own pages this month. What some insurers advertise is a waiver in defined cases, such as moving over from another gap policy without a break. Before you cancel anything, ask in writing:

• which waiting periods are waived, and for whom
• whether pre-existing conditions are still excluded, and for how long
• whether childbirth or a planned procedure carries its own waiting period

Your scheme's waiting periods are separate, and gap only tops up what the scheme pays. See waiting periods and exclusions.

• It is not medical aid. It only pays alongside an active medical scheme. Dis-Chem says its gap cover cannot be bought by holders of its medical insurance, and Sanlam and Old Mutual both require an existing scheme.
• It does not pay day-to-day costs such as GP visits, acute medicine or dentistry.
• It does not replace Prescribed Minimum Benefits. PMBs are the scheme's duty. See prescribed minimum benefits.
• It stops when your scheme cover stops. If you drop the scheme, the gap policy has nothing to top up.
• It may not cover what you choose to do. Ask whether co-payments for voluntarily using a non-network hospital are covered. On a network plan that can be a large amount. Bestmed's Beat1 Network, for example, charges a R15 025 co-payment for voluntary use of a non-network hospital.

It depends on how your plan pays specialists and how much risk you can carry yourself.

• You are on a hospital plan that pays specialists at 100% of the scheme rate. This is where shortfalls are biggest, and gap cover is the usual add-on. See hospital plans explained.
• Your plan pays specialists at a higher rate. Profmed's ProSecure Plus, for example, pays doctors at 200% of the Profmed Tariff. You may need less shortfall cover, but co-payment cover can still matter.
• You are on a network plan. Netcare describes its 500+ option as suited to members of a scheme with network limits, and its 300+ option as suited to comprehensive scheme members. That is the insurer's own description, so check it against your plan's rules.
• You are on an income-based or entry-level option. Check that the gap product accepts your scheme. Discovery's own gap product excludes KeyCare, for instance.

Compare the monthly premium with the shortfall risk on one admission.

You claim from your medical scheme first. The insurer then pays the shortfall to you or the provider. Kaelo says Kaelo Gap and Old Mutual Gap claims are finalised in 7 to 14 working days once all documents are received. Sanlam runs a paperless process for members of Fedhealth and Medshield, its preferred partner schemes.

If the insurer rejects or underpays a claim, complain to the insurer, then to the National Financial Ombud. The Council for Medical Schemes handles your scheme, not the gap policy. If the scheme underpays, follow the steps in how to complain to the CMS.

See also medical aid vs health insurance.