Gap cover buying checklist: what to check before you buy

• Scheme accepted. Does the insurer accept your scheme and plan? Discovery Gap, for example, is only for Discovery Health Medical Scheme members other than KeyCare.
• Cover multiple. How many times the scheme rate does it pay, and is it "up to" or "an additional"? In 2026 examples: Netcare's GapCare 300+ pays up to an additional 300%, Dis-Chem's Base up to an additional 500%, and Sanlam up to an additional six times.
• Annual limit. Ask which annual limit applies. The legal limit is R226 881.03 from 1 April 2026, up from R219 845.96. Some 2026 documents still show older figures.
• Sub-limits per event. Dis-Chem's Base lists R34,450 per event, Summit R68,370 and Sanlam R68,500. Ask about oncology, internal prosthetics and dental reconstruction.
• Co-payments and deductibles. Are scheme co-payments refunded? Is a co-payment for voluntarily using a non-network hospital covered? Sanlam lists unlimited co-payments and deductibles subject to the overall annual limit, and Netcare lists unlimited co-payment cover at Netcare hospitals.
• Out-of-hospital cover. Some products add out-of-hospital procedures or casualty visits. Netcare's 300+ and 500+ options and Dis-Chem's Summit do.
• Waiting periods. Sanlam and Old Mutual both state three months general and 12 months condition-specific. Ask about pre-existing conditions and childbirth.
• Age bands and price changes. See the next section.
• Family cover. Are children covered, and to what age? Is the family price a single premium?
• Claims. What documents are needed, and how long does payment take?
• Who is the insurer? Look for the insurer's name and FSP number on the quote, not just the seller's brand.

Gap premiums rise with age. 2026 published "from" prices show the pattern:

• Dis-Chem Gap Cover Base: R219 at age 18 to 39, R261 at 40 to 49, R325 at 50 to 59 and R386 at 60 and over.
• Old Mutual Gap Cover: R313 at 18 to 39, R340 at 40 to 59 and R416 at 60 and over.
• Sanlam Gap Cover: from R346 for individuals under 60, and from R899 for individuals aged 60 and over.

Check when the premium changes. Netcare's GapCare prices and Old Mutual's premiums both took effect on 1 January 2026, and you should ask for next year's price and how much notice you get. Prices are "from" figures and depend on the option, your age and your scheme.

Other 2026 "from" prices: NetcarePlus GapCare R345, GapCare 300+ R410 and 500+ R450, and Oneplan from R150 to R285 depending on the plan. Oneplan's page does not label which plan pays 200% and which pays 400%, so ask.

Gap cover fills the holes in your particular plan. Look at the plan first.

• Hospital plan paying specialists at the scheme rate: the largest shortfalls, so a higher multiple often matters. See hospital plans explained.
• Plan that pays specialists at a higher rate: you may need less multiple, but co-payment and sub-limit cover can still matter. Profmed's ProSecure Plus pays doctors at 200% of the Profmed Tariff, for example.
• Network plan: check co-payments for non-network hospitals. Bestmed's Beat1 Network charges R15 025 for voluntary use of a non-network hospital, and some gap policies may not pay a co-payment you chose to incur, so ask.
• Any plan with large co-payments on scopes or scans: check that the gap policy refunds them. See co-payments and sub-limits.

Buy the cover that plugs your plan's weak spots, not the most expensive option.

Gap policies set their own waiting periods, and, as we read it, the Medical Schemes Act limits do not govern insurance. The 2026 examples we could verify are three months general and 12 months condition-specific. We could not verify any product with no waiting period at all. Some insurers waive waiting periods you have already served if you move over from another gap policy without a break.

Before you cancel an existing policy, ask the new insurer in writing:

• Which waiting periods are waived, and from what date?
• Is cover in force on the day the old policy ends?
• Are pre-existing conditions covered, and after how long?

Your medical scheme's own waiting periods are separate. See waiting periods and exclusions.

• Keep the policy schedule, the disclosure notice and the premium confirmation.
• Give the insurer your scheme membership number so claims can be matched.
• On a hospital admission, ask your scheme for a pre-authorisation and tell the gap insurer if it asks to be notified. See how to claim.
• Kaelo says Kaelo Gap and Old Mutual Gap claims are finalised within 7 to 14 working days of receiving all documents.
• Complain to the insurer first, then to the National Financial Ombud. The CMS handles complaints about your scheme, not the gap policy. See how to complain to the CMS.