Gap Cover Options (2025) – At a Glance
Provider | Typical Monthly Premium* | Max % of Scheme Rate | Key Features | More Info |
Discovery Health Gap Cover | from R245 | up to 600 % | Maternity shortfalls, oncology, surgical excess, co-pays | |
DisChem Gap Cover | from R235 | up to 500 % | Emergency theatre, ambulance, co-pay benefits | |
Liberty Gap Cover | from R225 | up to 500 % | Family orientation, oncology boosters, specialist excess | |
Old Mutual Gap Cover | from R220 | up to 500 % | Maternity, trauma cover, co-payment inclusion | |
Sirago Gap Cover | from R195 | up to 500 % | Straightforward, hospital-plan oriented | |
Stratum Benefits Gap Cover | from R225 | up to 500 % | Trauma, oncology, co-pay shortfalls | |
Total Risk Admin Gap Cover | from R240 | up to 500 % | Trauma, maternity, co-payment top-up |
Gap Cover in South Africa (2025) – The Complete Guide
What Is Gap Cover?
Gap cover acts as a safety net when your medical aid does not fully cover specialist or hospital charges. When medical aids pay out at scheme rate (100–200%), but providers charge well above that, gap cover compensates for the difference—saving you from potentially massive bills after hospitalisation or surgery.
Why Gap Cover Matters
- Healthcare professionals often charge 200–600% of scheme rate.
- Medical aids pay only up to scheme rate or capped levels.
- Without gap cover, you’re responsible for the balance—post-procedure bills can be debt-inducing.
- Gap cover ensures bills are covered, regardless of what hospital fees spike to.
Why You Need Gap Cover in 2025
In recent years, specialist and surgeon fees have escalated, far outpacing the increases in what medical schemes will reimburse. Key drivers include:
- Rising medical inflation outpacing scheme payouts.
- Specialist demand, which allows for higher charges.
- Sublimit structures in schemes that leave many procedures partially covered.
- High maternity and oncology costs that regularly exceed scheme allowances.
With these trends, anyone with a hospital plan or full medical aid runs the risk of uncovered expenses—making gap cover essential.
What Does Gap Cover Include?
Standard gap cover typically includes:
- In-Hospital Shortfall Coverage – Pays the difference between what the scheme pays and what is charged, up to your policy limit.
- Co-Payment/Excess Cover – Covers out-of-pocket co-pay costs, like lens, MRIs or oncology consultations.
- Oncology Booster – Funds chemotherapy, radiotherapy, and cancer-related cover where schemes fall short.
- Trauma / Death Benefit – Lump sum payout in case of accidental death or severe injury.
- Maternity Shortfall Cover – Helps with obstetrician and anaesthetist billing during childbirth, optionally included.
Each provider has varying features and maximum limits—review these closely alongside your own medical aid policies.
Provider Overview – Alternative Options
In addition to your site’s specific offerings, here are other key providers worth comparing:
Up to 600% limit, includes maternity and disability payouts.
Flexible family plans up to 500%.
Focused on older clients, up to 500%.
Oncology and maternity excellence, up to 600%.
How to Evaluate Gap Cover Policies
When choosing a policy assess these key areas
Real-World Gap Cover Scenarios
How to Combine Gap Cover with Hospital Plans
Pairing a hospital plan with gap cover delivers robust medical protection:
✔ Hospital plan covers 100% scheme rate in hospital.
✔ Good gap cover ensures specialist or anaesthetist excess is covered—often at 500–600%.
✔ Total monthly cost for solid protection: R1,250–R1,500 (hospital plan + gap cover).
For example:
- Momentum Hospital Plan + Sirago Gap Cover ≈ R1,150/month
- Discovery Hospital Plan + Discovery Gap Cover ≈ R1,550/month
FAQs on Gap Cover
Yes—gap cover only works if you already have a medical aid policy in place.
No—gap cover applies only to hospital or in-hospital specialist costs.
Yes—usually 3 months for general claims, 12 months for maternity or pre-existing conditions.
No—these are short-term annual contracts that renew monthly; you may swap providers annually during open enrollment.
Summary – Is Gap Cover Right for You?
Profile | Gap Cover Benefit |
Young hospital-plan member | Buf for specialist excess |
Families & expecting moms | Removes risk around maternity bills |
Chronic/serious illness | Covers PMB caps or sub-limit shortfalls |
Older adults | Provides ICU, theatre, specialist expense coverage |
Next Steps
- Review each provider’s detail page – e.g. Discovery Health Gap Cover
- Calculate your preferred maximum limit (e.g. 500%)
- Evaluate family vs individual pricing
- Check waiting periods and policy integration with your scheme
- Apply or request quotes via your preferred provider
Let us know if you’d like a customized comparison table or application assistance.
Thando requires a knee surgery, specialist charges R45,000 while scheme pays R15,000. Without gap cover, Thando pays R30,000. With gap cover, this balance is covered—no surprise invoice at the end.