What Are Gap Cover and Top-Up Plans?

Many people want to know just what are gap cover and top-up plans? They are not sure if they need such plans or not, because they argue that they are already paying a hefty premium for the best medical aid. Medical aids have to make sure that they have enough funds to cover the health care needs of their members.

Gap Cover and Top Up PlansIn recent years, however, the fees charged by medical practitioners and specialists have skyrocketed and most medical schemes simply cannot pay these fees. This situation has forced them to limit the amount that they will pay for any given treatment or procedure.

In many cases the fee charged by the specialist or hospital is as much as four hundred percent above the amount that will be paid by the medical aid. It needs no degree in rocket science to figure out that the shortfall between the fee of the medical facility and the amount that will be paid by the scheme will leave the patient out of pocket. In fact, the shortfall can be financially ruinous. 

Is there a solution?

The short answer is “yes”. The Short-Term Insurance act no 53 of 1998 addresses the issue by allowing short term insurance companies to offer special products called Accident and Health policies. These products are designed to pay for the shortfall between the medical aid cover and the account tendered by the treatment facility or the medical practitioner.

Most insurance companies offer a wide variety of products that addresses this problem. In many cases members of existing medical aids can even obtain additional cover from their existing schemes. Those that are not members of a scheme can consider a hospital plan that makes provision for hospitalization but not for day-to-day medical care.

Do some homework before making a decision!

There is a bewildering array of products that provides for hospital cover, cash payments in cases of hospitalization and payments to cover the gap between the amount paid by the scheme and the actual cost of the treatment. Consumers should be sure to conduct thorough research before making a decision about gap cover. Here are some pointers:

  1. It is no use investigating additional cover unless one is perfectly up to date about exactly what cover is already in place. It is therefore vital to study the terms and conditions of existing medical plans. It is a good idea to ask advice and to do online research to find out just what the cost of medical treatment in and out of hospital is.
  2. Ask different insurance companies to provide a written quotation. In order to compare apples with apples, it may be wise to ask them to provide their quotations in a standard format.
  3. There are some excellent websites that will obtain a number of standard quotations from various service providers. They normally present their results in an easy-to-read and easy-to-compare format. A simple search using keywords such as “hospital plan”, “gap cover” or “top-up plans” will produce the desired results.


Many people that pay high premiums for the medical aids are irked by the need to take out additional cover. The ethics of the system is a matter of some on going controversy, but that will be of very little help when calamity strikes and large hospital bills become due. Without such cover consumers can easily be ruined financially. © Medical Aid Plan



Latest Posts

  • What Medical Schemes Offer and Do Not Offer

    Medical schemes in South Africa overview including a list of the biggest medical aids and the different plans available and their limits. Fill in the form and receive a comparative quote by email.

    Read more

  • What is a Medical Scheme

    What is a medical scheme Find all the answers here about medical aid schemes in South Africa and gap cover. Fill in the form and receive a comparative quote by email. Act now!

    Read more

  • Momentum Medical Aid

    Momentum Medical Aid information that South Africans can use to make informed decisions about medical scheme and hospital cover choices.

    Read more

Share via
Copy link