,

03 March 2023

Gap cover in South Africa is a type of insurance product that provides additional financial protection for medical expenses that are not fully covered by your primary medical aid.

female nurse with a male patient in a hospital.

Even with a medical aid, you may still be responsible for certain out-of-pocket expenses such as hospital co-payments, deductibles and fees for medical specialists that exceed your medical aid’s rates furthermore, Gap Cover is designed to help cover these additional expenses, so you don’t have to pay for them out of your own pocket.

A report published by the Council for Medical Schemes (CMS) in 2021 states that the total out-of-pocket payments by medical aid members increased from R29.8 billion in 2016 to R36.7 billion in 2021 at a consolidated scheme level including both open and restricted medical schemes. Moreover, this equates to 23% more out-of-pocket expenses paid by members from 2016 to 2021.

Having gap cover does not mean that all out-of-pocket expenses will automatically be covered, as this is a misconception throughout the industry which leads to frustration and confusion from gap cover policyholders.

Gap cover polices are not designed to cover day-to-day shortfalls namely, medicine, GP visits, and charges once your medical savings account has been depleted.

It is designed to cover in-hospital treatment and procedures and certain defined out-of-hospital procedures.

The table below contains some common procedures that frequently result in medical expense shortfalls additionally, the Rand amounts that were not covered by the medical aid and required payment by the member. These are actual Zestlife Gap Cover claim amounts paid during 2021/2022:

Examples of medical procedures that are frequently not covered in full by medical aids Examples of medical expense shortfalls paid by Zestlife Gap Cover in 2021/2022.
Natural Childbirth R40 189
Caesarean Section Childbirth R34 127
Tonsillectomy R62 445
Hernia Repair R57 263
Breast Cancer Surgery R48 142
Knee Replacement Surgery R42 937
Hip Replacement Surgery R58 143
Ankle Surgery R43 920
Shoulder Surgery R61 182
Hand Surgery R39 381
Foot Surgery R45 354
Lung Surgery R49 199
Brain Surgery R77 583
Liver Surgery R38 825
Kidney Surgery R39 206
Intestine Surgery R33 431
Heart Surgery R115 000
Heart Valve Replacement Surgery R124 721
Surgery for Fractured Arm R59 006
Eye Surgery R49 175
Ear Surgery R33 327
Cancer Treatment R146 694
Spinal Surgery R62 901

It is highly recommended that you choose the right gap cover option to suit you and your family’s needs and budget.

Contact us today and we will gladly assist you.

Click here for more product information or to apply online.

The information contained in this communication, including attachments, is not to be construed as advice in terms of the Financial Advisory and Intermediary Services Act of 2002 (“FAIS”) as the writer is neither an appointed representative of Zestlife, nor a licensed financial services provider as contemplated in FAIS. Please consult your Financial Adviser or Zestlife should you require advice of a financial nature and/or intermediary services.