Up to 75% of all Medical Aids do not pay Specialists’ bills in full. In fact, most only pay 1/3rd of the Specialist’s bill for in-hospital procedures. In addition, Medical Aids are passing on more expenses to their members in the form of co-payments, deductibles and sub-limits. These additional and unexpected financial expenses (shortfalls) become a burden unless you have GAP Cover.

The extent of cover and the cost there-of will be dependent on:

A) The age of the oldest member or dependent at the time of submitting your application.

B) Whether you select a Family pricing or an Individual-Member pricing option.

C) The categories or shortfalls you wish to protect against.


  • Gap Benefit – provides up to 500% additional cover where Specialists in-hospital charge more than your medical aid will pay.
  • Co-Payment Benefit – reimburses you the out-of-pocket expense where your medical aid imposes co-payments and/or deductibles. For example: Hospital Admission, MRI’s, CT Scans and Endoscopies.
  • Sub Limits Benefit – most medical aid schemes limit how much they will pay for certain procedures, operations and/or internal prosthetics. The sub-limits benefit helps cover the cost of these.
  • Cancer Benefit – medical schemes limit their liability for cancer treatment by either imposing a co-payment when treatment exceeds a certain cost threshold, or setting a limit on how much they will pay for oncology treatment in any calendar year. The Breast Reconstruction, Cancer Treatment Shortfalls and/or Cancer Treatment Top-up Benefits provide additional financial support in these instances.