The Future of Gap Cover under National Health Insurance

20 August 2019

Recently there has been much debate around the effects of a National Health Insurance for South Africans. Zestlife’s Sebastian Zoutendyk (Director) shares some thoughts around this issue.

Gap Cover pays for medical treatment cost shortfalls that are not covered in full by the medical scheme.  The future of Gap Cover in its current form is therefore paired to the role of medical schemes if and when the NHI is implemented. Zestlife will continue to monitor the implementation of the NHI and respond with policy enhancements that best serve to protect our policyholders from any medical expense shortfalls.

Zestlife fully supports the goal of the NHI to provide all South African’s with universal health care that is affordable, accessible and of an acceptable quality, irrespective of the ability to pay.  With South African taxpayers likely to carry the burden of universal healthcare, we simultaneously support the right that all South Africans should be free to choose a public or private healthcare treatment. NHI should not be at the exclusion of the right to utilise a medical scheme or private health insurance.

The National Health Insurance Bill was tabled in parliament on the 8th August 2019 with a targeted date for the implementation of 2026. The rollout of the NHI is expected to take place over an extended period which some policy analysts suggesting it may be restricted due to constraints on public finances.


The capacity of the public service to run the NHI has also been the subject of sceptism. William Gumede, Associate Professor at Wits University School of Governance says, “Policymaking is frequently to ideologically rigid, idealistic and pie-in-the-sky without taking consideration of cold realities”. Recently many policies, even when they have been absolutely necessary have been scrapped due to poor planning and court challenges.  In his view the same could happen to NHI.

The Bill is currently uncosted but Professor Gumede believes it will cost in excess of R250bn a year. The NHI Bill envisages that the funding required would be derived from a combination of increased taxes and abolishing medical scheme tax credits.

In the period prior to the NHI targeted implementation in 2026 no changes are likely to be made to the way medical schemes operate. The role of medical schemes after NHI comes into effect still requires much further clarity. But the Bill in its current form states: where patients choose not to follow the referral pathways, the NHI will not reimburse their care, and that they can then claim from private health insurance.

It appears likely that medical schemes will continue to offer alternative and complimentary cover for its members. We think the NHI will create additional opportunities for medical schemes and health insurance providers like Zestlife to service a need for private health care funding.

We will continue to offer the most comprehensive Gap Cover for medical treatment cost shortfalls.  If NHI leads to a change in the needs of policyholders, we’ll adapt our policy benefits to enable our clients continued funding to access the health care providers of their choice.

Click here to find out more about Zestlife Gap Cover and all its benefits.