As a member of a medical scheme, you may think you are fully covered for all in-hospital expenses, but in some instances, you are not. There are cases where there is a difference between what medical specialists charge in-hospital, and what your medical scheme will cover. These shortfalls can be high, especially for major procedures, and you might not have cash available to cover them. That’s where gap cover comes in.
Gap cover pays for this shortfall, so you’re not out of pocket and don’t suffer financially due to unexpected medical expenses.
Gap cover is typically restricted to in-hospital procedures, but some out-patient services are also covered.
The Council for Medical Schemes (CMS) stated in their 2024 annual report that in South Africa, over R32 billion is spent out-of-pocket each year on medical expenses. This underscores the importance of having gap cover to bridge the gap between medical aid payouts and actual healthcare costs.
Several gap cover administration companies have reported that 70% of all gap cover claims paid, are for specialist shortfalls and 20% for co-payments.
Below is a recent example of a gap claim shortfall:
| Provider | Claimed amount | Amount paid by scheme | Amount paid by gap cover |
| Neurosurgeon fee | R66 476.10 | R22 397.70 | R44 078.40 |
| Anaesthetist fee | R28 815.88 | R8 009.23 | R20 806.65 |
| Admission co-payment fee | R5 490.00 | R0 | R5 490.00 |
| Total | R100 781.98 | R30 406.93 | R70 375.05 |
We encourage all medical scheme members to connect with their Simeka Health consultant to discuss the benefits and value of taking up a gap cover.
Health-Connect 1/2025
Information obtained from: Medicalschemes.co.za, Sanlam Gap stats, Ambledown Financial Services