Everything Gap Cover

Demystified, De-jargoned, Defined.

BenefitsStratum Benefits Elite - 63 Stars (2018 benefit year)Zestlife Universal - 58 Stars (2018 benefit year)Sirago Ultimate - 55 Stars (2018 benefit year)Turnberry Premier - 57 Stars (2018 benefit year)Ambledown Gap Select - 52 Stars (2018 benefit year) 
Maximum rateAdditional 500%
[star rating="5"]
Up to 500%

[star rating="4"]
Up to 500%

[star rating="4"]
Up to 600%

[star rating="5"]
Up to 500% of what your Medical Scheme paid and with no limits on the number of times you may claim per year. [star rating="4"]
Get forms
Co-paymentsSubject to R150,000 per insured person per annum

[star rating="5"]
Subject to R150,000 per insured person per annum

[star rating="5"]
Subject to R150,000 per insured person per annum.

[star rating="5"]
Limited to R75,000 per Hospital event and per insured.

[star rating="5"]
Subject to R150,000 per insured person per annum.

[star rating="4"]
Get forms
Sub-limit coverSubject to R150,000 per insured person per annum.

No Star rating

R30,000 per policy per year for internal prosthesis Intraocular lenses are excluded

No Star rating
R100,000 per policy per annum with a sub-limit of R22,500 per claim.

No Star rating
Limited to R20,000 per admission and per insured.

No Star rating
Covers the charges above any sub-limitation imposed by your medical scheme for in-hospital procedures.

No Star rating
Get forms
Oncology benefit
Yes, but subject to Medical Scheme approved treatment plan being covered up to scheme rate / tariff within annual scheme oncology limit

No Star rating

Yes, but subject to Medical Scheme approved treatment plan being covered up to scheme rate / tariff within annual scheme oncology limit

No Star rating
Yes, but subject to Medical Scheme approved treatment plan being covered up to scheme rate / tariff within annual scheme oncology limit

No Star rating

Yes, but subject to Medical Scheme approved treatment plan being covered up to scheme rate / tariff within annual scheme oncology limit

No Star rating

Yes, but subject to Medical Scheme approved treatment plan being covered up to scheme rate / tariff within annual scheme oncology limit

No Star rating
Get forms
CasualtyLimited to R10,000 per policy per year and subject to R150,000 per insured per annum

[star rating="4"]
Limited to R10,000 per policy per year and subject to R150,000 per insured person per annum

[star rating="4"]
Limited to R10,000 per policy per year, R8,000 for trauma with R2,000 (gap portion only) for illness. Subject to R150,000 per insured person, per annum. [star rating="3"]Limited to R12,000 per admission. Subject to R150,000 per insured person, per annum. [star rating="5"]Limited to R10,000 per policy per year and subject to R150,000 per insured per annum [star rating="4"]
Get forms
Accidental dentalIn hospital dentistry is covered if due to accidental impact resulting in severe physical trauma
[star rating="5"]
R15,750 accidental tooth fracture cover is provided per person per year.

[star rating="4"]
No benefit
[star rating="3"]
No benefit
[star rating="3"]
In hospital dentistry is covered.
[star rating="5"]
Get forms
Premium WaiverGap cover policy premium will be paid for 12 months in the event of death, permanent disability or forced retrenchment of the premium payer. [star rating="5"]Only included as part of the Medical Scheme Contribution Waiver Benefit -
see info tooltip.

[star rating="3"]
Gap cover policy premium will be paid for 12 months in the event of death, permanent disability or forced retrenchment of the premium payer. [star rating="5"]Gap cover policy premium will be paid for 6 months in the event of death, permanent disability or forced retrenchment of the premium payer. [star rating="4"]No benefit [star rating="2"]
Get forms
Accidental death and Permanent disabilityA once-off payment of R25,000 in the event of the accidental death of the principal insured or spouse, and R5,000 for the accidental death of a dependent. [star rating="4"]A once-off payment of R50,000 in the event of the accidental death or permanent disability of the policyholder and all dependents.Permanent disability benefit ends at age 65.
[star rating="3"]
A once-off payment of R12,000 in the event of the accidental death of the principal insured, R8,000 for adult dependent, and R5,000 for the accidental death of a child dependent. Subject to 6 month waiting period.[star rating="3"]A once-off payment of R25,000 per insured in the event of the accidental death or permanent total disability. [star rating="5"]No benefit
[star rating="2"]
Get forms
Waiting period general3 months

[star rating="4"]
Waiting periods apply for pre-existing conditions and childbirth

[star rating="5"]
3 months

[star rating="4"]
3 months

[star rating="3"]
3 months

[star rating="4"]
Get forms
Waiting period - pre-existing Yes, 12 months

[star rating="4"]
Yes, 12 months

[star rating="4"]
Yes, 12 months

[star rating="4"]
Not applicable
[star rating="5"]
Yes, 12 months

[star rating="4"]
Get forms
Waiting period - proceduresYes

[star rating="4"]
Not applicable
[star rating="5"]
Yes

[star rating="4"]
Yes

[star rating="3"]
No specific procedures excluded/waiting period
[star rating="5"]
Get forms
Waiting period -cancerPreviously diagnosed cancer will be regarded as a pre-existing condition and excluded for 12 months [star rating="5"]Pre-diagnosed cancer is covered provided the insured is in remission for 5 consecutive years. [star rating="4"]Previously diagnosed cancer will be regarded as a pre-existing condition and excluded for 12 months [star rating="5"]Previously diagnosed cancer will be regarded as a pre-existing condition and excluded for 12 months [star rating="5"]Previously diagnosed cancer will be regarded as a pre-existing condition and excluded for 12 months [star rating="5"]
Get forms
Use of non DSPLimited to 1 co-payment up to max R8,500

[star rating="5"]
1 payment up to max R8,600

[star rating="5"]
Covered up to R8,800 per incident

[star rating="5"]

Co-payment up to an amount of R9,000 per family, per year.

[star rating="4"]
No benefit for using hospital or day Clinic outside your medical scheme's designated Network.
[star rating="3"]
Get forms
Out-patient proceduresYes

[star rating="5"]
Approximately 50 listed out-patient shortfalls are covered.
[star rating="5"]
Yes

[star rating="5"]
Defined list of procedures covered and subject to R150,000 per insured, per person, per annum.
[star rating="5"]
63 procedures as defined in the policy wording.

[star rating="5"]
Get forms
Who is coveredMain member & spouse, even if they are not on the same medical scheme. All dependents registered on Main member or spouse's medical scheme.

[star rating="5"]
Main member & spouse, even if they are not on the same medical scheme; All dependents registered on Main member or Spouse's medical scheme; Individuals of all ages.

[star rating="5"]
All dependents are covered under the principal member’s medical aid.

[star rating="5"]
Main member, Spouse, and child dependents.

[star rating="5"]
Direct family only

[star rating="5"]
Get forms
PremiumR295 Individual
under 64; R470 Individuals (65+); R355 families under 64; *R575 families over 65

R324 Individual
under 55; R409 Individual (55 - 64); R466 Individual (65+); R409 families under 65; R466 families over 65

R311Individual under 64; R353 per Family under 64; R412 for Individuals 65 and over; R468 for families 65 and over

R337 per family under 65; R458 per family 65 and over
65

R390 Individuals 65 and under; R585 for Individuals 66 and over

Get forms

Information correct as of: 13 December 2018

Most GAP cover providers remunerate financial advisors for generating business for them. This is often by way of a monthly fee equal to a percentage of the premium you pay. In most cases, the fee that the financial advisor earns is equal to 20% of the premium. This is however a cost to the insurance company and does not increase the monthly cost you would otherwise pay for your Gap cover.

The Editors do not feel that there is merit in showing you every single product or offering, and we do from time to time, limit the number of comparable products shown. In such circumstances, we will always list all the products or offerings that we do not provide researched information on, enabling you to do further research or make further enquiries on those products should you choose to. We have listed below, all those additional Gap cover products that we have not considered in our table above.

Essential Gap cover, Complimed, Xelus, Talksure, Sanlam, Resolution Gap cover, Admed, Cura, Instantlife, Liberty, African Unity, Discovery, Alexander Forbes, Admed.

  • Do Gap products pay for prescription medication?

    Chantelle 20:3616.08.17
  • WellSpent 09:0317.08.17

    Unfortunately not. Gap covers are intended to cover costs, relating specifically to hospitalisation.

  • Will I qualify for GAP cover if I am on a medical health insurance plan and not a medical aid fund?

    Cecelia 10:5915.08.17
  • WellSpent 14h0015.08.17

    Unfortunately not. The single biggest prerequisite for becoming a policyholder for any Gap product is that you are a member of a medical aid scheme.

  • I am struggling to find a dental cover that covers Periodontal procedures – most cover Orthodontic procedures. Which one can you recommend?

    Winston 17h3325.07.17
  • WellSpent 10h1126.07.17

    Gap covers generally only cover accidental dental work, eg: non-planned work that requires emergency work to be performed. The limits are relatively low and many don’t even provide cover at all.

    If you’re looking for an insurance product that covers future possible advanced dentistry or orthodontics, then Stratum Benefits has such a product. It won’t help you instances of pre-existing conditions, but if you’re anticipating future possible orthodontic work for either yourself or your kids, then this product could be suitable.

  • What does Premium waiver mean?

    Gillian 08h2726.07.17
  • WellSpent 09h5026.07.17

    A Premium Waiver is a when your Gap cover provider, will waive the premiums due on your Gap (and possible medical aid cover), in the event of death, or disability. It is normally capped at a specific amount per month, and for a limited number of months.

    An example is Stratum Benefits premium waiver, which waives yours premiums on your medical aid for 6 months, but limited to no more than R4,500 per month.

    The idea is that this affords you, or your surviving family some breathing room to deal with other financial issues in the event of very serious medical conditions, or death

    All Gap covers have different premium waiver features, so each should be considered on its own merits.

  • I am on Discovery Classic Priority medical aid and recently had a hospital procedure where I had to pay the first R3,600 hospital fees. Would I be able to claim this from Gap cover?

    Peter 09h2319.07.17
  • WellSpent 10h3423.07.17

    This would depend on what Gap cover you are a member of. Some Gap covers would cover this co-payment, others would not.

  • How much is Turnberry Seniors Gap cover for the 2017 benefit year?

    Janet 20h1522.07.17
  • WellSpent 10h2723.07.17

    The current cost per family is R255 per month, per family.

    If you are looking for a comprehensive Gap cover, please do to take the time to get some advice as to what might be appropriate for your personal circumstances, as Turnberry’s Senior product, covers some quite specific needs. By comparison, Turnberry’s Premier Gap cover product for people over the age of 65, is R434 per month, for the 2017 benefit year.

  • Are over 65’s covered?

    Suresh 19H4311.07.17
  • WellSpent 11:5712.07.17

    Yes. As per recent changes to the law governing Gap cover, there are no age restrictions applicable. So long as the applicant is a principal member or beneficiary of a registered medical aid scheme, they can take out Gap cover.

  • How does Stratum compare to Xelus Gap cover?

    Zelna 8:1230.06.17
  • WellSpent 9:2530.06.17

    Xelus seem to offer a comprehensive Gap cover product. Like Stratum, they also offer an additional 500% over 1x medical scheme rates. We’re not aware as to the premiums for the 2017 benefit year. We have not done a comprehensive review of their Gap product, but like all insurance products, get hold of the policy documentation and take the time to consider all aspects, knowing what it is that you specifically need from your Gap cover.

    We’d suggest you use the categories we’ve created in our table, to interrogate their product.

  • Can Gap cover be used in conjunction with a hospital plan?

    Danwine 12H5726.06.17
  • WellSpent 13:0826.06.17

    Short answer: Yes

    Not to be confused with hospital insurance, though. That normally only pays you an amount of money for each day that you are in hospital.

    For so long as you are a member of a registered medical scheme, you can take out a Gap cover policy.

    We discussed this in quite a bit of detail in an article which can be found here.

  • If I was at a casualty facility but not admitted to the hospital after the visit and my medical aid did not pay the doctor and/or blood tests/Radiology due to MSA being exhausted. Will my gap cover pay it?

    Eileen 10H0420.06.17
  • WellSpent 10:5220.06.17

    Most Gap products have specific policy wording for admissions to casualty. The typical wording, grants benefits for admissions to casualty, for up to RX,000 per policy, per year. The amount that the policy covers ranges from about R6,000 p.a to R10,000. This would be for any costs incurred whilst admitted to casualty including doctors, radiology, and pathology. So yes, if your medical aid did not cover any casualty costs specifically, your Gap cover would cover those costs up to the policy limits, which all depends on your specific policy provider’s limits on casualty admissions.

    However this is only when you’re in casualty. Any hospital visit subsequent to the casualty visit would be dealt with outside of any casualty benefit

     

  • How do gap cover companies treat payments when someone is on a Savings medical aid option with a Medical Savings Account once the savings in that account are depleted?

    Belinda 17h0313.06.17
  • WellSpent 13h2314.06.17

    The interaction between your MSA and Gap cover is fairly simple. If your MSA pays for the cost (which is really just your medical aid), then your Gap cover won’t, as Gap cover is meant to pay for things that your medical aid won’t – BUT only in instances where the cost arose as a result of being hospitalised.

    Gap cover will seldom pay for day-to-day and out-of-hospital benefits; This is what your MSA is for.

    SO if your MSA runs dry, your Gap will continue to pay for any gap that arises, between what you’re invoiced and what your medical aid pays, BUT only for costs incurred relating to being hospitalised.

    To the extent you are able to advise your medical aid NOT to settle certain costs arising whilst in hospital from your MSA, you could keep your MSA balance untouched, and rather have your Gap cover pick up that cost.

  • How do gap cover companies treat payment out of Medical Savings Accounts?
    I am on a medical aid plan that has a medical savings account (MSA).

    If I had to go for a procedure, say an MRI, and I had to pay R1,000 out of my MSA and the rest (R1,500) was paid out of my hospital plan. How much would my gap cover (assuming the gap cover covers MRI’s) cover? Would it be zero since the full R2,500 was paid out of my “medical aid”, or would I be refunded for the amount paid from my MSA.

    Sunshine 11H5311.06.17
  • WellSpent 10:2512.06.17

    If the Medical Scheme settles any costs out of your MSA, then your Gap policy will not settle the claim and will not refund you. In instances where you require a scheduled medical procedure, it would be better to instruct your medical aid not to cover any shortfalls out of your MSA, such that you could claim from your Gap policy.

  • I am the principal member of a medical aid scheme and my wife is a beneficiary of the scheme. Which is the best company for our needs. I am 77 years and in good health. My wife is 68 years old.

    Abdoolhay 09h4408.06.17
  • WellSpent 10h1108.06.17

    To definitely say which Gap cover is the best for your needs is likely not a fair answer to give, without knowing your particular medical and financial circumstances.

    We have previously written an article which can be found here, which can be used to interrogate any Gap cover. To our mind, the takeaway wording is as follows:

    Arguably the most important factor is the “maximum rate”. This is the rate at which the GAP cover pays the shortfall that you’ve incurred. Most of the GAP covers listed, will settle a shortfall of up to 500%, meaning that if the medical specialist invoiced you for R5, 000 and your medical aid paid R1, 000, then the R4, 000 would be settled.

    We say that this feature is critical, as it embodies what a GAP cover is all about – settling your medical bill shortfalls. If your whole rationale for taking out GAP cover is to protect yourself from paying personal-finance-destroying medical bills, then you want insurance against that; and you want a lot.

    Some GAP covers only provide 100% or 200% shortfall cover. However medical specialists who only charge you 2 or 3 times medical aid rates are a rare breed, and you’re more likely to be charged a much higher multiple. Therefore, make sure that the GAP cover you choose covers shortfalls that likely match the kind of shortfalls you want to insure yourself against.

    The decision is ultimately yours and it may be that you don’t require a Gap cover that pays high multiples. If you are looking for potential options, the comparison table we have provided does list a host of suitable Gap cover providers, who offer high multiples of shortfall cover; Stratum Benefits Elite covers the most.

    I’d suggest you consider those provided, request forms and have a discussion around the potential provider, and whether they are suitable for your needs.

  • Are there any gap covers for medical insurance?

    Riaan 10h0805.06.17
  • WellSpent 13h3905.06.17

    Unfortunately not. Gap cover is only available where the insured person is a member of a South African registered Medical Scheme. Gap cover policies are policies issued in terms of the Short Term Insurance Act, as are Medical Insurance policies.

  • Is there an inclusive Gap cover available for an adult dependent (age 80) that belongs to a member’s medical aid.

    Nadia 14h1031.05.17
  • WellSpent 15h3931.05.17

    As per the recent amendments to the legislation governing Gap policies, there are no age limitations for insured persons. If the dependent is a member of a medical aid scheme, albeit not the principal member, they may be covered under a Gap policy.

  • Are day to day shortfalls covered?

    Zanele 14h4429.05.17
  • WellSpent 10h2630.05.17

    Unfortunately not. Gap cover is only intended to cover costs arising from hospitalisation, that a medical aid scheme does not cover. There may specific day procedures that do not require admission to a hospital that your medical aid would cover, and any shortfall on these costs may be covered by your Gap cover provider.

  • Is there an age limit for obtaining Gap cover?

    Gordon 13h0723.05.17
  • WellSpent 13h1523.05.17

    Gap cover providers used to impose age limits, but these have been dropped. As such, anybody can take out Gap cover.

  • Does a Gap policy cover pathology/lab services?

    Samukelisiwe 11h2619.05.17
  • WellSpent 12h0319.05.17

    Different providers of Gap cover, have different policies when it comes to pathology costs, by way of example:

    In the case of Stratum as profiled in the comparison table above, pathology costs are specifically covered when they relate to you being hospitalised. Pathology costs specifically related to oncology benefits are also catered for. Their casualty benefit specifically includes pathology but would be part of the limited benefits of R10,000 p.a for the benefit year.

    Zestlife also offer pathology as part of its offering on an unlimited basis. Their casualty benefit includes pathology, but also has a limit as to what this total casualty benefit is per year.

    It would be best to consider your Gap provider’s policy documentation for the benefit year in question. It is safe to assume that Gap providers will only settle pathology costs when they relate to hospital admission of some kind, be it planned or casualty.

    Pathology costs won’t be settled as an out-of-hospital benefit.

  • Are there any GAP covers that provide out-of-hospital benefits for MRI/Scans/specialised dentistry, that would cover my costs, should my medical aid savings cover some costs and I cover the rest?

     

    Antoinette 15h0511.05.17
  • WellSpent 16h0911.05.17

    Gap cover is predominantly designed to cover the shortfalls associated with major medical, in-hospital claims. Stratum Elite does however provide some cover for out of hospital MRI’s/CAT scans provided the medical aid pays a portion from the major medical portion i.e. they will cover the co-payment up to R2,500. A co-payment can be though of ‘excess’, like one would pay with short-term insurance.

    Regarding dentistry, Stratum also offer an add on benefit which might be what you’re looking for.

  • Hi

    I see that most gap cover providers have a three month waiting period for claiming. Does this mean that I cannot claim at all during that period?

    Mario 14h2008.05.17
  • WellSpent 14h5108.05.17

    The 3 month waiting period is really there to prevent people claiming for pre-existing type conditions. If you are involved in an accident or require emergency medical hospitalization for a non-pre-existing condition, your Gap cover provider will likely cover your costs. Again, each provider is different so be sure to do your research.

  • I have Admed Gap cover offered via our company. Would it be possible to do a comparison against the top 5 and potentially highlight any shortcomings?

    Henry 08:5127.03.17
  • WellSpent 09:0027.03.17

    For the 2017 benefit year, Admed offer both a ‘Supreme’ product as well as a ‘Primary’ product (caters for people wanting a more affordable option). Without getting into the policy wording for both options, I would always consider the shortfall that the Gap cover provides, regardless of who provides it.

    In the case of Admed products, their policy wording quotes as follows:

    The maximum amount that we will pay towards this shortfall is calculated as 2x (or 200% of) the amount paid by your medical scheme, up to the value of the actual shortfall.

    We wrote an article which can be found here, which can be used to interrogate any Gap cover. To our mind, the takeaway wording is as follows:

    Arguably the most important factor is the “maximum rate”. This is the rate at which the GAP cover pays the shortfall that you’ve incurred. Most of the GAP covers listed, will settle a shortfall of up to 500%, meaning that if the medical specialist invoiced you for R5, 000 and your medical aid paid R1, 000, then the R4, 000 would be settled.

    We say that this feature is critical, as it embodies what a GAP cover is all about – settling your medical bill shortfalls. If your whole rationale for taking out GAP cover is to protect yourself from paying personal-finance-destroying medical bills, then you want insurance against that; and you want a lot.

    Some GAP covers only provide 100% or 200% shortfall cover. However medical specialists who only charge you 2 or 3 times medical aid rates are a rare breed, and you’re more likely to be charged a much higher multiple. Therefore, make sure that the GAP cover you choose covers shortfalls that likely match the kind of shortfalls you want to insure yourself against.

    The decision is ultimately yours and it may be that you don’t require a Gap cover that pays high multiples.

  • Where can I find out if I have GAP cover and with whom? Or who can I contact to get the information from?

    Quintus 9:4317.03.17
  • WellSpent 10:2617.03.17

    GAP cover is a specific short-term insurance product. If you had previously taken out GAP cover, you would have completed application forms for it. GAP cover is not a free ad-on to any specific medical aid or hospital cover product.

    If you are interested in taking out GAP cover, you can consider the products we have compared in the table above, and if any of them appeal to you, you can request the application forms from the table itself.

  • What is Gap cover?

    Zeenid 11:5723.11.16
  • WellSpent 12:0223.11.16

    Gap cover is a short-term insurance product, that pays you the difference arising between what medical service providers charge you and what your medical aid scheem pays in terms of their scheme tariff. Gap cover only covers expenses related in in-hospital procedures.

  • Why might I need Gap cover?

    Olivia 14:3319.11.16
  • WellSpent 14:3619.11.16

    It is not uncommon for medical specialists to charge up to 400% or 500% of medical scheme tariffs, while your medical aid would only pay for up to 1 times the scheme tariff. This leaves you with a payment ‘gap’. Gap cover pays you this medical payment gap ensuring that you are not out of pocket for any medical costs.

  • Who can apply for Gap cover?

    Paul 15:3716.11.16
  • WellSpent 15:4016.11.16

    Any person who is a member of a registered medical aid scheme can apply for Gap cover. Some Gap cover providers may apply age limits for people 65 years and older. There are however changes that will see the age cap being dropped going forward.

  • Do I use Gap cover alongside my medical aid?

    Dean 09:0809.11.16
  • WellSpent 09:1209.11.16

    Yes. Gap cover is designed to complement your medical aid membership. You also cannot take out a GAP policy without being a member of a medical aid.

  • Does Gap cover have waiting periods?

    Nosi 16:2302.11.16
  • WellSpent 16:2702.11.16

    Yes. Each Gap cover provider will have their own specific rules regarding waiting periods, but there are generally waiting periods for things like child birth, and cancer and oncology. Read the policy document for each provider to ensure that you understand what waiting periods might apply to you. We have also given a lot of detail above as to how the various providers apply the waiting periods.

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