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Will Your Medical Aid leave you exposed to in-hospital claim shortfalls or procedure co-payments?

gap top-upUnderstanding the Gap in Your Medical Aid benefits

Medical aid plans help protect you against the high costs of healthcare. However, they may leave you exposed to in-hospital claim shortfalls or procedure co-payments. Rising medical inflation has led to a gap between the fees charged by private providers and the rates paid by medical aids.

Even the more expensive plans can fall short of covering the entire cost, leaving you with an unexpected financial burden.



Bridging the Financial Gap

To help reduce any in-hospital claim payment gap and protect you from high healthcare costs, you need to join a gap cover or top-up plan today!
It acts as a financial safety net, bridging the gap between what your medical aid pays and the actual cost of your treatment.

Why You Need a Gap or Top-up Plan

Are you aware of the rate at which your medical aid pays in-hospital specialists?
Knowing this is important, because there can be a large difference between what your medical aid covers and the actual cost of treatment.
This gap can be a serious threat, especially during medical emergencies or planned surgeries.

As a medical aid member, joining a Gap or Top-up plan is not just advisable; it's essential.

Understanding the Gap in Medical Aid benefits

Over the years, medical costs, particularly those of surgeons, anaesthetists, and specialists, have increased beyond the rates that medical aid plans pay - in fact, up to 5 times what your medical aid pays!

Even though schemes now offer more expensive plans, paying 2 or 3 times the medical aid rate, they may not be enough to cover your total hospitalisation cost.
(Generally, hospital and ward fees are charged at the scheme rate and are fully covered.)

At the beginning of a year, all medical providers and medical schemes decide on the cost of a procedure.
This is known as the scheme (medical aid) rate and schemes then pay at that rate.

Examples of Gap Cover claims:
In June 2023, Zestlife Gap Cover showcased its effectiveness with three significant payouts:

  1. Heart Surgery Specialists Shortfalls: R 120,000
  2. Brain Surgery Specialists Shortfalls: R 75,126
  3. Spinal Surgery Specialists Shortfalls: R 116,222

Zestlife processed 2,001 claims during this period, with an impressive average payment time of only 7 days!

Zestlife Gap Cover offers 3 options:

  1. Universal Gap Cover plan for the top, comprehensive cover including extensive protection against various health risks.
    Ensure your peace of mind with this plan.
  2. Essential Gap Cover plan offers offering affordable cover for most frequent medical claim shortfalls, and additional financial protection.
  3. Optimal Gap Cover offers high-level benefits for individuals younger than 35, ensuring a perfect match for their needs.

Family Cover is for the main medical aid member, spouse and family dependants including adult dependants, on the same medical aid.
Family cover also extends to a policyholder’s spouse and mutual children that are registered as dependants on the spouse’s medical aid.

Family protection, financial security – Zestlife Gap Cover for all your needs.


See the full benefits and limits here ...

zest gap application

Additional Benefits: Extended Cancer Cover

Get the peace of mind that comes with Zestlife's Extended Cancer Cover Benefit.

Protect yourself from the unexpected costs of a cancer diagnosis.
In the event of a first time cancer diagnosis, a benefit of R100,000 or R200,000 will be paid.
Immediate relief from the financial burden associated with cancer treatment, without waiting periods – Zestlife Gap Cover has you covered!

Unique Policy Benefit

There are NO general waiting periods or condition specific waiting periods that withhold cover after the commencement date of the policy!

Claim pay-outs are either made to you or directly to the treating doctors, specialists or medical service providers, at your discretion.

Swift claim processing, minimal waiting – Zestlife is the answer you've been waiting for!

What Gap Cover Doesn't Include

Gap plans do not cover day-to-day medical expenses.
Additionally, if your medical aid would have never covered a specific claim, the gap plan will not provide benefits either.

Gap Cover is not a medical aid plan, nor a substitute for medical aid.
It is an insurance policy, providing cover for claims that your medical aid does not fully pay for.
A claim must have been paid by a medical aid before a gap claim will qualify for payment.

If you have medical aid, you should have Gap Cover to complement it.
It is your best solution to protect you from in-hospital medical aid claim shortfalls.

zest gap applicationZest Gap Application


Talk to me .... I am here to help you - at no charge!
Send me your questions and concerns. I'll answer them for you.

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The plan works with any medical aid!
Enhance your cover without having to change from your medical scheme!

Note: Benefits are plan dependant. It is important to note that this product is specifically designed to help you meet the private tariffs charged by doctors, anaesthetists, radiologists, physiotherapists and specialist surgeons, for in-patient treatment. It does not cover the actual cost of the hospitalisation.

No benefits are payable for a period of 12 months from the start date of cover in respect of medical conditions, for which in the 12 months before the start date of the cover, medical advice, diagnosis, care or treatment was received or would reasonably have been recommended. Pregnancy before the start date of cover will be regarded as a pre-existing condition and any pregnancy and birth related claims will be excluded for 12 months from the start date of the cover.
Terms and conditions do apply.

You must consult the schemes/company product brochures and rules for comprehensive benefit descriptions.

We will offer you the best help at no cost!

whatsapp083 655 2164


income protectionMedical aid pays healthcare costs.
What if a disability stops your income?

peter pyburn brokerpeter pyburnPeter Pyburn - Authorised Financial Services Provider, fully licensed to render financial services since 1991. Death and Disability Planning; Retirement Planning; Investment Planning; Healthcare and Estate Planning. More...

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Last update: April 6, 2024

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