Will Your Medical Aid leave you with a shortfall or procedure co-payment in-hospital?

gap top up

Gap Cover for Medical Aid explained.

Your medical aid does not guarantee that you won't have to pay money towards your medical costs!
Over many years of excessive medical inflation, the gap between what medical services cost and what a medical aid pays have increased.

Private providers are now charging up to 5 times the basic medical aid rate your plan may pay!

In reply, healthcare plans now offer - more expensive plans - that pay at 2 or 3 times the medical aid rate.
But that is still not enough and the possible gap in claim that you could be liable for can be substantial!

Unfortunately, South Africa is a violent country and the threat of you being hospitalised is very real.
Do not think, because you have medical aid you will not face a financial threat of short-paid hospital costs - you easily can!

Do you now at what rate your scheme pays in-hospital specialists?

If you are a medical aid member, you need a Gap or Top Up plan.

It is an inexpensive way to make sure you will not have to pay for short-paid hospital claims!
Don't think twice - join today as Gap Cover is really necessary and most certainly worth it!


Medical schemes pay in-hospital costs at different rates. 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. Schemes then pay at that rate.

If you use private providers, they can charge what they want - known as the private rate. This can be 5 times more expensive than the medical aid rate!

Medical aids now offer more expensive plans, that will pay up to 3 times their scheme rate, to help you with that claim shortfall.
(Generally, hospital and ward fees are charged at the scheme rate and are fully covered.)

But these rates of payment are not sufficient to prevent a potential claim shortfall.

Here are 9 common hospital procedures, including specialist and anaesthetist fees.
You can clearly see the potential payment you would have if you are on a plan that pays medical aid rates in-hospital.

Some procedures not fully covered by medical aids.2020 shortfalls paid by Gap Cover
Natural ChildbirthR 19 250
Caesarean Section ChildbirthR 29 645
TonsillectomyR 8,391
Hernia RepairR 35 622
Breast Cancer SurgeryR 54 158
Hip Replacement SurgeryR 16 877
Spinal SurgeryR 147 782
Cancer TreatmentR 120 240
Heart SurgeryR 165 654

Just look at a hip replacement ... specialist and other private providers can - and do - charge R 25,300. But a medical aid pays only R 8,423 of these costs.

You have to pay R 16,877!
That's not going to help your recovery at all!

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.


1. You can use network providers who are linked to your medical aid because, they will charge what the plan pays. So, you should never experience an in-hospital claim shortfall.

2. Or, best of all, join the 2021 Best Top Up/Gap plan that will pay any in-hospital shortfall and co-payment.

top up coverNow, you can even consider a lower cost medical aid plan, that pays at medical aid rates because, you are safe in the knowledge you are protected against high hospital costs!

Yes, your Top Up will make good on any shortfalls or co-payments you have, up to a legislated maximum of R 173,000 per family, per year.

Every medical scheme member should have an insurance-based Top up plan.
It is a necessary part of having a full in-hospital benefit, healthcare plan!

These plans also offer benefits for other costs that your medical aid may not pay in full like:

Please note that:

  1. no day-to-day medical expenses are covered by Gap plans.
  2. if your medical aid would never have paid for a claim - in terms of their rules - neither will the Gap plan.


You also face financial threats of co-payments for certain procedures like:

ProcedureListed Co-Payment
GastroscopyR 4 450
MRIR 3 685
Admission feeR 1 650
Dental procedureR 6 820

In order to contain costs, medical aids are increasingly imposing co-payments for treatments and procedures, like MRI, CT, ultrasounds, scopes, prosthetics and scans.

These are amounts that need to be paid to the hospital/day clinic/radiologist before undergoing certain procedures.
More expensive plans have fewer co-payments.

You pay a portion of the costs for procedures and your medical aid pays the rest. This is your co-payment.

CoPay will pay your co-payments for procedures performed in-hospital as well as some specified out-patient procedures including MRI, CT and ultrasound scans.

There are many of these plans available and they will cover most medical aid shortfall and co-payments, but this one is the most comprehensive for the price!

Premiums from R 284 per family, per month for a very valuable plan!

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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.
A standard 3 month waiting period is applicable from the date of inception to policy, and pre-existing conditions may be excluded for a minimum 12 months.
There is a total exclusion for any pre-diagnosed cancer and 12-month maternity exclusion. Terms and conditions do apply.

With this cover, YOU will NEVER fear the pressure of financial shortfalls in the unfortunate event of hospitalisation.

You owe it to yourself and your family to investigate these Top Up and Gap Cover Cover policies!

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

We will offer you the BEST HELP FOR FREE!

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Last update: May 6, 2021


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