As a medical aid broker, I’m in the business of helping companies manage risk for their employees. I analyse, strategise, and find the most cost-effective medical aid plans. But no matter how good the medical aid plan is, I always have the same conversation with finance and HR managers: “Now, we need to add Gap Cover.”
Almost every time, I get this question: “But Debbie, we’re already paying for a good medical aid. Is Gap Cover really worth it?“
It’s a fair question. You’re already spending thousands per employee on medical aid premiums. Why add another expense?
My answer is always the same. Yes, it is 100% worth it. In fact, it’s non-negotiable.
Not having Gap Cover is like buying a R5 million house but refusing to pay for insurance… because you’ve already paid for the house. It’s a risk that makes no financial sense.
Let me show you why.
The Big Misconception: “My Medical Aid Covers 100%”
This is the single most dangerous misunderstanding in South Africa’s healthcare industry.
When your medical aid plan says it covers “100% of the Scheme Rate,” it does NOT mean 100% of the bill.
- The Scheme Rate (or Medical Aid Rate) is a specific rand amount your medical aid has decided it will pay for any given procedure. It’s a number they’ve set, not a number your doctor has to obey.
- The Private Rate is what specialists (surgeons, anaesthetists, radiologists) actually charge. They are private businesses and can charge whatever the market will bear.
And here’s the problem: Specialists regularly charge 300%, 400%, or even 500% more than the Scheme Rate.
The “gap” is the massive, uncapped difference between the R5,000 your medical aid pays and the R25,000 your anaesthetist charges.
And that bill goes straight to you.
Let’s Talk Real-World Numbers
You’re not paying for Gap Cover “just in case.” You’re paying for it because these shortfalls happen every single day.
Data from gap providers in 2024 shows that the average “large loss” gap claim—the shortfall on a single hospital event—is now sitting at over R63,000.
Let’s look at common, non-disaster scenarios:
- Childbirth (C-Section):
- Gynaecologist & Anaesthetist Bill: Can easily be R45,000.
- Medical Aid (at 100% Rate) Pays: R15,000.
- Your Shortfall (The “Gap”): R30,000.
- Appendectomy (Emergency):
- Surgeon & Anaesthetist Bill: R38,000.
- Medical Aid (at 100% Rate) Pays: R12,000.
- Your Shortfall (The “Gap”): R26,000.
- Cancer Treatment:
- This is the scariest one. Many medical aids put a co-payment (e.g., 20%) on cancer treatments once you hit a certain limit (e.g., R240,000).
- 20% of a R150,000 biologic drug treatment is R30,000… for one treatment.
- Gap Cover is designed to fund these specific oncology-related co-payments and shortfalls.
Now, look at the cost of Gap Cover. A good family plan might cost R500 – R700 per month.
Your R63,000 shortfall from one single event would have paid for your Gap Cover policy for over 9 years.
Suddenly, the premium doesn’t look so expensive, does it? It looks like the smartest R700 you could possibly spend.
“But My Company is on a Top-Tier Medical Aid Plan!”
This is another common objection. “Debbie, we put our execs on the top R10,000/month plan. It covers 300% of the scheme rate. Surely they don’t need it?”
They need it just as much, if not more.
- Specialists Charge More: Specialists often know what plan you’re on and will charge accordingly. A 300% plan is great, but it’s useless if the specialist charges 500% of the scheme rate. The gap is still 200%.
- Co-Payments: These top-tier plans often force co-payments for specific procedures (like scopes or joint replacements) to manage costs. A Gap Cover policy pays that R8,000 co-payment for you.
- Oncology Limits: As mentioned, cancer co-payments and limits can apply to all plans, even the very best ones.
Why Gap Cover is a “No-Brainer” for Your Corporate Benefits
As an employer, your goal with a benefits package is to provide a “duty of care” and financial security for your team.
If you only provide medical aid, you are leaving your employees exposed to the single greatest financial risk associated with their health.
- Financial Stress: An employee hit with a R60,000 shortfall is a stressed, distracted, and struggling employee. They may ask for loans, take on debt, and lose focus at work.
- Perceived Value: When an employee gets that R60,000 bill, they don’t blame the specialist. They blame the medical aid you provide. They feel the R8,000/month you’re paying for their plan is “useless.” All the goodwill you built by providing the benefit evaporates.
By adding a small R500/month Gap Cover policy (which is also tax-deductible for the business), you complete the puzzle. You turn that R60,000 shortfall into a R0 bill.
You transform a moment of financial terror into a moment of genuine gratitude for the comprehensive cover you’ve provided.
My Final Verdict
So, is Gap Cover worth it?
It is the only thing that ensures your medical aid can actually do the job you pay it to do: protect you from catastrophic financial loss. Without it, your medical aid is an expensive, half-finished solution.
Don’t leave your team exposed. Don’t leave yourself exposed.
I specialise in building complete corporate healthcare solutions—that means a smart medical aid plan, a robust gap cover policy, and proactive corporate wellness. Call me, Debbie Pretorius, today, and let’s close the gap in your company’s cover for good.