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Peter Pyburn - Authorised Financial Services Provider fully licensed to provide expert financial services since 1991.

What most people unfortunately learn the hard way…

You pay your medical aid every month and presume you’re covered. That’s insurance, right?

Then something unexpected happens.
A hospital stay.
A procedure.
A specialist visit.
And afterwards… the bills come...

Not just the part your medical aid covered, but the part it didn’t!

It may be a few thousand rand. But it can also be for R20,000, R30,000… or even more.

This is the gap that catches people off guard because it’s not explained clearly upfront.

Why these shortfalls happen (and why they’re increasing)

Medical schemes in South Africa pay claims based on set tariff rates, often referred to as “scheme rates”.

But many private specialists charge well above those rates, up to 500% more!

(According to the Council for Medical Schemes (CMS), specialists may charge between 200% and 500% of scheme rates, depending on the procedure and provider.)

So this is what actually happens:

• Your medical aid pays up to its limit (for example, 100% or 200% of the scheme rate).
• The specialist charges more than that.
• You are responsible for the difference.

And that difference is the gap this insurance plan offers cover for.

Sadly, it’s becoming more common because healthcare costs in South Africa continue to rise faster than general inflation.
(Source: Statistics South Africa CPI releases and medical inflation reports)

In plain English, Gap cover is a short-term insurance plan that helps cover the difference between what your medical aid pays and what your healthcare providers charge.

It works alongside your medical aid. Not instead of it.

Think of it like this:

• Your medical aid is your foundation.
• Gap cover fills in the cracks.

Without it, you carry that financial risk yourself.

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Here is a simple example

You need a procedure that costs R60,000.

Your medical aid covers R30,000 (at 100% of the scheme rate), but your specialist charges R60,000.

Without gap cover you will pay that shortfall.
However, with a gap cover plan, most or all of that R30,000 shortfall can be covered (depending on your actual plan limits).

Now that can certainly help you recover more quickly!

Who gap cover is really for

Many people think gap cover is only for older individuals or people with health issues. Not so!

It’s really about financial protection and not health recovery.

• If you’re on a hospital-only benefit plan, you have a higher risk of shortfalls.
• If you have a family membership, one unexpected event affects everyone's benefits.
• If you want to know the bill will be paid, gap cover removes any uncertainty.
• Gap cover is an essential way you can protect yourself from large bills.

Every medical aid member needs gap cover because accidents and emergencies are unpredictable and can (and do) happen to all of us.

Gap Insurance Plan

Gap cover includes:

• Benefits for specialist shortfalls (often up to 500% of scheme rate).
• Co-payment benefits for certain procedures.
• In-hospital fee shortfall protection.
• Cancer treatment shortfall benefits (on selected plans).

There are several gap plans available and each plan has limits, terms, and waiting periods.
That’s why choosing the right plan for your needs matters.

Why working with a medical aid broker like us actually matters
Gap cover isn’t complicated… but choosing the right plan can be.

Not all gap cover policies are the same.

Some differences that matter:

• Annual limits.
• Specific exclusions.
• Waiting periods.
• Premium increases over time.

The wrong gap cover plan will leave you financially exposed and that’s where our advice makes a real difference.

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We are here to help you understand your options clearly before you make a decision.

No pressure. No confusing jargon. Just practical guidance based on your personal situation.

What you can expect from us

A simple process where:

• You tell us your current medical aid.
• We present suitable gap cover options.
• We explain what each one actually covers.
• You choose what fits your needs and budget.

Join a Gap cover plan that actually protects you!

Find an affordable plan matched to your medical aid.

Before you decide, consider this:

The real question isn’t: "Do I?" — but rather: “If something happens tomorrow, could I comfortably pay the shortfall myself?”

If your answer is no (or even maybe), then gap cover becomes less of an option and more of a necessity!

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

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