Checklists
Gap cover buying checklist for South Africa
By Naledi Mokoena · 6 min read · Updated 24 June 2026
Gap cover is a separate, low-cost insurance policy that pays the in-hospital shortfall when your specialist charges more than your medical aid's rate. To choose well, check the shortfall multiple it covers, the annual limit, the sub-limits on co-payments and cancer, and the waiting periods.
Use the checklist below before you buy. Gap cover is not a medical aid and cannot replace one; it sits on top of your plan.
For anyone on a plan that pays at 100% of scheme rate, gap cover is often the cheapest way to close the biggest financial risk.
What gap cover does and does not do
Gap cover pays the difference between what your specialist charges in hospital and what your medical aid pays, up to a set limit. It typically also covers certain co-payments and sub-limits.
It does not pay day-to-day claims, it does not cover you if you have no medical aid, and it is regulated as insurance, not as a medical scheme. It is a top-up, not a substitute.
The buying checklist
- Shortfall cover: how many times the scheme rate does it pay (look for high multiples)?
- Annual limit: the total it will pay per person per year.
- Co-payment cover: does it refund scope, scan and procedure co-payments?
- Sub-limits: any caps on cancer, internal prosthesis or specific procedures?
- Waiting periods: general (often three months) and a longer one for some conditions.
- Age limits and price increases as you get older.
- Whether it covers your whole family on one policy.
Waiting periods to expect
Most gap cover applies a general waiting period of around three months and a longer waiting period (often up to 12 months) for pre-existing conditions and sometimes for childbirth. If you switch gap cover providers without a break, some will waive waiting periods you have already served. Ask, and get the answer in writing before you cancel an existing policy.
Match gap cover to your medical aid
Gap cover matters most if your plan pays in hospital at 100% of scheme rate, because that is where the largest shortfalls appear. If your plan already pays at 200% or 300%, you need less shortfall cover but may still want the co-payment benefits. Buy the gap cover that plugs your specific plan's weak spots, not the most expensive option.
Frequently asked questions
What is gap cover?
Gap cover is a separate insurance policy that pays the in-hospital shortfall when a specialist charges more than your medical aid's rate. It also often covers certain co-payments. It is a top-up to your plan, not a replacement for medical aid.
Do I need gap cover if I have medical aid?
Often yes, especially on plans that pay at 100% of scheme rate, where specialist shortfalls can run to tens of thousands of Rand. Gap cover is cheap relative to that risk. On richer plans paying at 300% you may need less.
What should I look for in a gap cover policy?
Check the shortfall multiple it pays, the annual limit, co-payment cover, sub-limits on cancer and prosthetics, waiting periods, and age rules. Use the checklist above and compare two or three policies on the same points.
Is there a waiting period on gap cover?
Usually a general waiting period of about three months and a longer one, often up to 12 months, for pre-existing conditions and sometimes childbirth. Switching without a break may waive served waiting periods - confirm in writing first.
Can gap cover replace my medical aid?
No. Gap cover only pays shortfalls when you already have medical aid, and it is regulated as insurance, not as a medical scheme. You must keep an active medical aid for gap cover to pay anything.
Does gap cover pay day-to-day claims?
No. Gap cover is for in-hospital shortfalls and certain co-payments, not GP visits, medicine or dentistry. For day-to-day costs you need a plan with savings or an above-threshold benefit, or you pay cash.
