Does your Medical Aid Cover Enough? - RegInsights

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Life is unpredictable, so despite thinking you have planned for every medical eventuality and are financially covered, you can still end up financially ruined by expensive doctor’s bills which are not covered entirely by your medical aid scheme.

Medical aid schemes use a price guideline (Reference Price List) issued by the Department of Health to determine their medical scheme rates for payment of services or treatments provided by medical practitioners or healthcare providers.

Medical Aid CoverThese rates are very important to consumers because they determine the amount of money that your medical aid scheme is willing to pay for a consultation, hospitalisation or medical procedure.

Unfortunately, doctors, hospitals and other medical service providers are not bound to medical aid scheme rates, and they can charge up to 500% above the medical scheme rates.

Because of the discrepancy between what the service provider charges and what your medical aid will cover, you are left liable for a possible shortfall in costs.

Have you been left “Out of Pocket”?

Debt due to medical expense shortfalls not covered by your medical aid when you are hospitalised can result in a huge financial burden and stress which can hinder your speedy recovery.

Private healthcare cost in South Africa is very high.  Gap cover is designed as a solution available to consumers to mitigate the risk from shortfall surprises due to hospitalisation and other healthcare related expenses.

What is gap \vcover?

Gap cover is not a medical aid and it is also not a replacement for your medical aid.  Gap cover is a short-term insurance product that provides additional cover up to certain limits for clients already on a medical aid. It may be offered by your own medical aid, or by another short-term insurer.

Gap cover should not be confused with a daily health benefit which pays out a predetermined amount per day (normally with a 24-hour waiting period) which can be spent as you need when hospitalised. 

The gap cover products vary in range of benefits from entry- level to comprehensive cover.

Why worry about unpaid medical expenses?

Pre-negotiate and take control:


  • Request specialists to charge medical aid tariffs
  • Use specialists in your medical aid’s network
  • Request cash discounts and claim your payment back from your medical aid

Invest in a gap cover solution:

Gap cover provides peace of mind to you and your family that the in-hospital medical expense shortfalls between what your medical aid scheme pays from the savings or risk benefit and what your doctor, specialist or hospital charges, is sufficiently covered, subject to the plan selected.

In addition to in-hospital expenses, certain medical aid procedures performed out of hospital are also covered by gap cover.

Important questions to consider when selecting gap cover


  • Are there waiting periods applicable?

Gap cover, as with medical aid, is subject to certain waiting periods.


  • Are there entry age or other restrictions?

Entry age cut-offs for cap cover policies vary from zero age restrictions to age 60 or 65 years.

Gap cover policies also vary from open to all members of medical schemes, to cover restricted for members of a specific medical aid scheme.


  • Are there overall limits for the gap cover?


  • What is excluded from the cover?


  • Are there co-payments applicable?

Due to the number of gap cover options and gap cover providers available in South Africa, selecting the right product for you and your family is a difficult task.

MyWealth Investments can assist you with selecting the right gap cover provider. For more information on gap cover and other financial services needs, speak to your Financial Advisor, or contact MyWealth Investments.

The information provided in this article is for information purposes only and should not be considered as financial advice.

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