Medical
Medical aid and gap cover
A medical scheme and gap cover are not the same product. A medical scheme pays for healthcare according to its rules, including prescribed minimum benefits. Gap cover is short-term insurance that can help with certain shortfalls. It has limits. It does not replace a medical scheme.
Medical schemes
Medical schemes, often called medical aid, are regulated under the Medical Schemes Act, not as ordinary short-term insurance. They use open enrolment and community rating, and they must cover prescribed minimum benefits. The scheme rules still decide what is paid, at what rate, and in which hospital.
We help you compare options against how your family actually uses healthcare: a GP, chronic medicine, pregnancy, or a specialist you already see. A benefit that looks wide on a summary can be narrow in the rule book. We read the rule book.
Gap cover
Specialists and hospitals sometimes charge more than the scheme rate. Gap cover is an insurance policy designed to help with some of that difference, subject to the policy limit, the waiting periods and the exclusions. It does not pay every shortfall. It will not pay where the scheme paid nothing, except where the policy explicitly says otherwise.
We will tell you the limit in rand and the waiting period before you take the policy. A gap policy with a low premium and a low annual limit may not do the job you have in mind.
General information only. This page is not personal advice and it is not an offer. Product rules, tax and your own circumstances decide what is suitable. Read the official documents before you decide.
Questions we hear
What is the difference between medical aid and gap cover?
Medical aid is a medical scheme. It is the core cover for healthcare and is regulated under the Medical Schemes Act. Gap cover is a short-term insurance policy that can contribute to certain shortfalls between the scheme rate and the provider’s charge. You generally need the scheme. Gap cover does not stand in for it.
Does gap cover pay every shortfall?
No. Policies have annual limits, sub-limits, waiting periods and exclusions. Some charges, such as certain appliances or co-payments the policy does not list, remain yours. Ask us to point at the limit that would have applied to the procedure you are worried about.
Can a broker help me compare medical schemes?
Yes. We can explain the differences in plain language and help you gather a quote. The scheme you join is still your contract with that scheme. We will not pretend one scheme is right for every family.
Related
Tell us what you are planning for
A quote, a question, or a look at the retirement illustration. We reply from matt@ncj.co.za. What you read here is general information, not personal advice.