Gap cover is an essential financial safety net for medical aid members in South Africa. It protects you from the difference between what your medical scheme pays (usually 100-200% of the Medical Scheme Tariff) and what private specialists charge (often 400-500% or more of MST). Without gap cover, a single hospital procedure can leave you with a bill of tens of thousands of rands.
Below is a list of 10 top gap cover providers currently operating in South Africa, based on their offerings, benefit limits, and market presence.
10 Top Gap Cover Providers in South Africa (Current Year)
Comparison of Top Gap Cover Providers
The table below summarises key features of 10 leading gap cover providers in South Africa.
| Provider | Key Features | Annual Limit (Per Person) | Best For | Typical Premium (Single) |
|---|---|---|---|---|
| Bloom (Cinagi) | Up to 600% cover, maternity benefits, cancer lump sum, casualty cover | ~R198,660 | Comprehensive cover with extra benefits | R150–R250/month |
| Discovery Health | Up to 600% cover, maternity gaps, oncology, surgical co-payments | Varies by plan | Discovery medical aid members | R150–R300/month |
| Dis-Chem | Emergency hospital events, theatre costs, ambulance, selected co-payments | Varies by plan | Emergency-focused cover | Budget-friendly |
| Old Mutual | Maternity shortfalls, trauma benefits, in-hospital co-payments | Varies by plan | Maternity & trauma benefits | R150–R250/month |
| Sirago | Straightforward, affordable, works with hospital plans | ~R198,660 | Budget-friendly simple cover | From R130/month |
| Stratum Benefits | Tiered options, flexible limits, oncology benefits | Up to R223,000 | Flexible benefit tiers | From R350/month (family) |
| Total Risk Administrators (TRA) | Four tiers from Basic 300 to Absolute Plus; up to 700% cover | ~R223,000 | Scalable options for budgets | From R99/month (Basic) |
| Zestlife | Universal, Essential & Optimal options; casualty and cancer extras | Varies by option | Customisable coverage | From R276–R591/month |
| GapCover.co.za | Primary (300%) & Elite (500%) options; simple structure | R198,660 | Simple percentage-based cover | From R130/month |
| Liberty | Family-orientated, oncology boosters, specialist excess protection | Varies by plan | Families wanting oncology cover | R150–R300/month |
Detailed Provider Profiles
1. Bloom (Cinagi)
Bloom offers two gap cover options: Gap Core and Gap Max, underwritten by Cinagi.
Key Benefits:
– Tariff shortfalls covered up to 500% (Core) or 600% (Max)
– Maternity: R425–R650 per consult for 2nd/3rd trimester
– Cancer diagnosis lump sum: R40,000 (Core) or R50,000 (Max)
– Casualty cover up to R18,000 per event
– Waiver of medical aid contributions after death/disability (up to R8,000/month)
– Accident cover up to R34,000 for death/disability
Best for: Members wanting extra benefits like cancer lump sums and casualty cover alongside hospital gap protection.
2. Discovery Health Gap Cover
Discovery is the largest medical scheme administrator in South Africa. Its gap cover integrates with Discovery medical aid plans.
Key Benefits:
– Covers specialist shortfalls up to 600%
– Includes maternity-related gaps
– Oncology treatment cover
– Surgical excesses and in-hospital co-payments
Best for: Discovery medical aid members who want seamless integration.
3. Dis-Chem Gap Cover
Dis-Chem entered the gap cover market focusing on emergency hospital events.
Key Benefits:
– Theatre costs cover
– Ambulance services
– Selected co-payment shortfalls
Best for: Members who want emergency-focused coverage for key hospital event costs.
4. Old Mutual Gap Cover
Old Mutual is one of South Africa’s largest life insurers and offers gap cover as part of its financial product suite.
Key Benefits:
– Maternity-related shortfalls
– Trauma benefits
– Cover for certain in-hospital co-payments
Best for: Members wanting maternity and trauma benefits alongside co-payment assistance.
5. Sirago (Sirago Underwriting Managers)
Sirago offers straightforward, affordable gap cover designed to work alongside hospital plans.
Key Benefits:
– Simple benefit structure
– Covers specialist shortfalls
– Works with any medical aid
Best for: Budget-conscious members who want simple, no-frills coverage. GapCover.co.za uses Sirago as its underwriter.
6. Stratum Benefits
Stratum is a gap cover specialist offering tiered options with flexible limits.
Key Benefits:
– Tiered gap cover options
– Flexible benefit limits
– Oncology and trauma-related benefits
Best for: Members who want flexible tiers and the ability to choose benefit limits.
7. Total Risk Administrators (TRA)
TRA offers four scaling gap cover products, ensuring there is an option for everyone.
Product Tiers:
– Basic Cover 300 (from R99/month): Up to 300% cover for in-hospital shortfalls
– Vital Cover Plus (from R394/month): Up to 700% cover, co-payment cover, oncology benefits
– Super Cover Plus (from R417/month): Comprehensive with extra oncology benefits
– Absolute Cover Plus (from R681/month): Unlimited oncology extender cover, up to 700% cover
Best for: Members who want scalable options from entry-level to comprehensive.
8. Zestlife
Zestlife has over 16 years in the gap cover market, offering Universal, Essential, and Optimal options.
Premium Structure for the Current Year:
– Universal Gap Cover: R591/month (under 55), R784/month (55-64), R930/month (65+)
– Essential Gap Cover: R429/month (under 55), R549/month (55-64), R645/month (65+)
– Optimal Gap Cover: R276/month (under 35)
Optional Benefits:
– Cancer Cover: R124–R206/month for R132,000–R264,000 cover
Best for: Members wanting customisable options with strong cancer benefits.
9. GapCover (GapCover.co.za)
This provider offers simple percentage-based cover options underwritten by Sirago.
Plan Options:
– Primary: Up to 300% cover | from R130/month
– Elite: Up to 500% cover | from R220/month
– Combined: Up to 500% cover | from R318/month
Annual Limit: R198,660 per beneficiary, per year
Best for: Members wanting straightforward percentage-based cover at entry-level prices.
10. Liberty Gap Cover
Liberty, a major financial services group, offers family-orientated gap cover.
Key Benefits:
– Family-orientated cover
– Oncology boosters
– Protection against specialist excess charges
Best for: Families wanting oncology boosters and specialist shortfall protection.
What Is Gap Cover and Why Do You Need It?
The Problem: Medical Scheme Tariffs vs. Specialist Charges
Medical schemes pay according to a benchmark rate called the Medical Scheme Tariff (MST). Most schemes pay between 100% and 200% of MST for in-hospital procedures.
However, many private specialists charge significantly more — often 400%, 500%, or even 700% of MST. The difference between what your medical aid pays and what the specialist charges is called a “shortfall” or “gap,” and it is billed directly to you.
Without gap cover, a single surgical procedure can leave you with an unexpected bill of R50,000 or more.
What Gap Cover Covers
Gap cover typically includes:
– Tariff shortfalls – The difference between specialist charges and scheme payments (up to a specified percentage, e.g., 300%, 500%, or 700%)
– Co-payments – Fixed amounts your medical aid requires you to pay for specific procedures
– Sub-limits – When your medical aid caps payment for items like internal prosthetics, MRI/CT scans, or robotic surgery
– Casualty/emergency treatment – Accident or crime-related injuries requiring hospital out-patient care
– Oncology co-payments – The 20%, 25%, or 50% co-payments applied after reaching oncology thresholds
How to Choose the Right Gap Cover Provider
Before selecting a provider, consider these factors:
Understand Your Medical Aid Plan First
Ask yourself:
– Do I need to use Designated Service Providers (DSPs) or specific networks?
– What co-payments apply to common procedures?
– What is my specialist coverage rate (100%, 200%, or more)?
– Are there sub-limits on devices like prostheses?
Compare Key Features Across Providers
– Tariff shortfall percentage – Some cover up to 300%, others up to 700%
– Annual limit – The maximum payout per person per year (typically R198,000–R223,000)
– Maternity benefits – Important if you are planning a pregnancy
– Oncology benefits – Cancer treatment co-payments and lump sums
– Casualty cover – Emergency treatment after accidents
Consider Premium Affordability
– Entry-level plans start from as low as R99/month for individuals
– Comprehensive plans range from R250–R600/month for individuals
– Family plans typically cost R300–R500/month
Check Waiting Periods and Exclusions
Most gap covers have waiting periods before benefits become available. Pre-existing conditions may be excluded initially.
Verify the Claims Process
Ask about:
– Required documentation
– Claim processing timelines
– Whether claims can be submitted online
Red Flags to Watch For
Be cautious of:
– Vague benefit descriptions
– Unclear exclusions
– Limited claims support or complicated processes
Frequently Asked Questions
Q: Can I get gap cover without medical aid?
A: No. Gap cover is an FSCA-regulated insurance product that operates only as a top-up to a registered medical scheme. If you cancel your medical aid, your gap cover lapses automatically.
Q: What is the typical annual limit for gap cover?
A: The Demarcation Regulations set the annual cap at approximately R219,000–R223,000 per beneficiary per year. Most providers offer limits in this range.
Q: How much does gap cover cost per month?
A: Entry-level individual plans start from R99–R130 per month. Comprehensive individual plans range from R250–R600 per month. Family plans typically cost R300–R500 per month.
Q: Does gap cover cover out-of-hospital specialist consultations?
A: Some gap cover plans include cover for out-of-hospital specialist consultations that would attract a co-payment if performed in hospital. Check your specific policy.
Q: Are cancer treatments covered by gap cover?
A: Yes, most gap cover providers include oncology benefits covering the 20%, 25%, and 50% co-payments applied after reaching your medical aid’s oncology threshold. Some also offer a once-off cancer diagnosis lump sum benefit.
Q: How do I claim from gap cover?
A: The claims process varies by provider. Generally, you submit the specialist’s invoice, your medical aid’s statement of benefits, and proof of payment. Some providers offer online submission portals.
Q: Can senior citizens get gap cover?
A: Yes, but premiums are higher. For example, some providers charge higher rates for members aged 65+. Other providers offer Over 65’s rates at double the standard premium.
Q: What happens if my medical aid premiums increase?
A: Gap cover premiums are reviewed annually and may increase in line with healthcare inflation.
Summary Table: Gap Cover Premium Ranges
| Plan Type | Monthly Premium Range (Single) | Monthly Premium Range (Family) | Best For |
|---|---|---|---|
| Entry-Level (300%) | R99 – R130 | R197 – R300 | Budget-conscious members |
| Mid-Range (400–500%) | R150 – R250 | R300 – R400 | Balanced cover and cost |
| Comprehensive (600–700%) | R250 – R420 | R400 – R600 | Maximum protection |
Key Resources
– FSCA (Financial Sector Conduct Authority): www.fsca.co.za – Regulates gap cover providers
– Council for Medical Schemes (CMS): www.medicalschemes.com – Regulates medical schemes
– Your Medical Aid Provider – Check your scheme’s specialist rates and co-payments
– Individual Gap Cover Providers – Request quotes directly from the providers listed above
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Conclusion:
Gap cover in South Africa is often provided by notable medical aid providers, and may allow for more savings. However, it is not ideal for everyone. Gap cover is ideal for: Young professionals on hospital plans, Families with dependents and frequent specialist visits, Retirees needing enhanced oncology or other treatment.
Disclaimer: This information is based on current available data. Benefit limits, premiums, and terms are subject to change annually. Always verify current details on each provider’s official website before purchasing.