Gap Cover vs Medical Aid: Understanding the Difference
health-and-home
Medical Gap Cover is often misunderstood, leaving many South Africans unsure whether they need it if they already have Medical Aid. The truth is, Medical Aid doesn’t always cover the full cost of certain procedures or in-house specialists, which can leave you with unexpected bills. That’s where Auto&General Insurance’s Gap Cover can help you bridge those shortfalls. In this guide, we’ll detail the key differences between the two so you can protect your finances and make informed healthcare decisions.
Medical aid shortfall: the silent killer
What is Gap Cover?
As outlined by Moneyweb, Gap Cover is a short-term insurance product designed specifically for Medical Aid members in South Africa. It bridges the gap between what your Medical Aid pays and the amount healthcare professionals charge – covering co-payments, deductibles, and tariff shortfalls. It supplements your medical cover but is not a replacement for it.
The risks of going without Medical Gap Cover
Hidden costs of medical treatment:
Many South Africans believe their Medical Aid covers everything. However, private hospitals and specialists often bill above the medical scheme tariff – sometimes charging up to 300% or more of what Medical Aid pays, leaving policyholders to pay the remainder. Consider this: your specialist bills R25,000, but the Medical Aid covers only R10,000 – you’re left owing R15,000 – even with a comprehensive Medical Aid plan.
Unexpected financial strain
Without it, such gaps can significantly impact savings or push families into debt. This is especially worrying during emergencies, surgeries, and treatments like cancer care, which can have huge out-of-pocket costs.
Compromised or delayed treatment
If you can’t immediately settle the outstanding balance, critical treatment may be delayed – or you may opt for less effective alternatives due to financial constraints.
Impact on your family’s finances
These unexpected medical bills impact your finances—they have a knock-on effect on your household budget, draining savings set aside for important life events such as studying or retirement.
Peace of mind vs. constant worry
Medical Insurance is all about peace of mind. Knowing you’re covered against overwhelming deficits means you can focus on getting better, instead of worrying about how you’ll pay the bill.
As you can see, the importance of Medical Gap Cover for you and your family is significant.
6 key differences between Medical Aid and Medical Gap Cover
Understanding the difference is vital for South Africans who want both access to quality healthcare and protection against unforeseen costs. While these two products work together, they serve completely different purposes.
1. What they cover
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Medical Aid: Covers a wide range of healthcare needs such as everyday expenses, hospital stays, GP consultations, and certain procedures.
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Gap Cover: Steps in when private hospitals or specialists charge more than Medical Aid tariffs, paying the difference.
Scenario: You undergo surgery that costs R70,000. Your Medical Aid pays R30,000 according to scheme rates. Without cover, you must pay the outstanding R40,000 yourself. With the cover, the difference is reimbursed.
2. Scope of protection
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Medical Aid: Comprehensive but limited by capped rates and scheme rules.
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Gap Cover: Narrower focus – only protects you from financial “gaps” in medical costs, not everyday healthcare.
3. Monthly costs
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Medical Aid: Premiums vary widely depending on your plan, but are typically higher.
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Gap Cover: More affordable as it’s supplementary, not a standalone healthcare solution.
4. Day-to-day healthcare
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Medical Aid: Depending on your plan, it may include dental, GP visits, prescribed medications, and optometry.
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Gap Cover: Does not pay for routine healthcare – it only applies to hospitalisation and specialist shortfalls.
5. Claims process
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Medical Aid: Pays healthcare providers directly at the scheme’s approved rate.
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Gap Cover: Reimburses you for the outstanding balance once the Medical Aid claim is processed.
Scenario: You consult with a specialist who charges R8,000. Medical Aid pays R5,000 at its rate. You pay the specialist in full, submit the paperwork, and your cover reimburses the R3,000 difference.
6. Legal requirement
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Medical Aid: Governed by the Medical Schemes Act, offering prescribed minimum benefits (PMBs)
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Gap Cover: Classified as a short-term insurance product under insurance law, with annual limits set by the regulator.
FAQs – common questions about Medical Aid vs. Medical Gap Cover
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Do I still need Gap Cover if I already have Medical Aid?
Yes. Medical Aid only pays up to the scheme tariff, but private hospitals and specialists often charge more. Medical Gap Cover from Auto&General Insurance means you won’t be left to pay the difference out of pocket.
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Can Gap Cover replace Medical Aid?
No. It is a complementary insurance product. It only pays for shortfalls once your Medical Aid has settled its portion. It does not cover day-to-day health expenses, GP visits, or medication.
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Is Gap Cover expensive compared to Medical Aid?
No. It is generally much more affordable because it only protects against specific limitations. Medical Aid premiums are higher since they cover comprehensive hospital and day-to-day benefits.
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Who should consider Medical Gap Cover in South Africa?
Anyone with Medical Aid. If you want extra protection from unforeseen medical bills – especially when facing hospitalisation, seeing specialists, or undergoing procedures – it’s a smart choice.
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How do I claim from Gap Cover?
Your claim is first processed by your Medical Aid. Once they’ve paid their portion, you submit the statements and proof of the difference to Auto&General Insurance for reimbursement.
Get a Medical Gap Cover Quote
Ready to protect yourself from pricey medical out-of-pocket bills? Then get a Medical Gap Cover quote from Auto&General Insurance and get security knowing you’re covered. Our friendly team is here to help answer any questions you may have.
