In short: Gap cover is a short-term insurance policy that pays the difference between what a specialist or hospital charges and what your medical aid pays for in-hospital treatment. You must belong to a medical scheme to buy it. By law, a gap cover policy can pay out at most R226,881 per insured person for the year from 1 April 2026. Premiums depend on the insurer, your age and the cover level, so get quotes. This is general information, not financial or insurance advice.
What gap cover actually pays for
Medical schemes pay specialists, anaesthetists and hospitals at the scheme’s own rate, for example 100% or 200% of that rate. Many specialists charge more. The difference is called a shortfall, and without gap cover you pay it.
A typical gap cover policy can pay for:
- Specialist and anaesthetist shortfalls for in-hospital procedures.
- Some co-payments your scheme charges, for example for certain procedures or for using a non-network hospital, depending on the policy.
- Sub-limits for things like cancer treatment shortfalls or casualty visits, on some policies.
It does not replace medical aid. It cannot pay for things your scheme should cover as a medical scheme benefit, and it will not pay for day-to-day costs like GP visits or scripts.
The 2026 limit
Gap cover is allowed under the Demarcation Regulations, which keep these policies separate from medical schemes. The regulations cap the total a gap cover policy may pay per insured person per year. The cap started at R150,000 in 2017 and rises every 1 April by the previous year’s inflation.
- 1 April 2025 to 31 March 2026: about R219,846 per person.
- 1 April 2026 to 31 March 2027: R226,881 per person, after National Treasury applied the 2025 inflation rate of 3.2%.
The next change is due on 1 April 2027. Many policies pay up to this full limit, but some cheaper ones have lower limits, so read the schedule.
What gap cover costs
There is no single price. Premiums depend on:
- The insurer and the level of cover (policies pay shortfalls up to different multiples of the scheme rate).
- Your age, and whether you cover only yourself or your family.
- Your medical aid option. Some insurers price differently for hospital plans and comprehensive plans.
- Extras such as cancer cover, co-payment cover or a premium waiver if the main member dies.
Premiums usually increase every year. Ask each insurer for the 2027 premium before you sign, and compare at least three quotes.
Waiting periods and exclusions
Most policies apply a general waiting period and a longer waiting period for conditions you already have. Check:
- How long the general and pre-existing condition waiting periods are.
- Whether the waiting period is waived if you move from another gap cover policy without a break.
- Which procedures are excluded, such as cosmetic surgery or some dental work.
Do you need gap cover?
Gap cover tends to make sense if:
- Your medical aid pays specialists at 100% of the scheme rate, which is common on lower and network options.
- You have a family, a planned procedure or a pregnancy coming up.
- You could not pay a shortfall of R10,000 or more from savings.
It may matter less if your option already pays specialists at a high rate and you use specialists who charge the scheme rate. If you are downgrading your medical aid for 2027, gap cover is worth pricing at the same time. See how to get affordable medical aid.
Before you buy
- Check the insurer is a licensed insurer and that the policy is sold by an authorised financial services provider.
- Read what the policy pays as a percentage of the scheme rate, and the annual limit.
- Check how claims work: most insurers want the scheme’s claim statement and the provider’s account.
- Ask about the 2027 premium increase.
Gap cover premiums are not medical scheme contributions, so they do not count for the medical scheme fees tax credit. See deductions people forget for what does count.
Last checked: 16 October 2026. This article is general information and not financial or insurance advice. Policy terms differ, so read your policy wording or speak to an authorised adviser.