Gap Cover2022-06-22T09:08:08+02:00

The importance of gap cover

You may think your medical scheme provides full cover. Sadly, this wont always be the case.


I have medical scheme cover.
Why do I need gap too?

Healthcare is expensive and all medical schemes are forced to impose limitations on the cover they provide. These shortfalls can place a huge toll – not only on your finances, but more importantly, the treatment outcomes of your loved ones.

Our gap plans start from R355 per month ranging in cover to meet your budget and tailored to meet your family’s specific requirements. Get a detailed quote in just 2 minutes or review the below information to understand the gaps and make an informed choice about which plan will best meet your most critical priorities.


To help you select a gap plan that meets your most critical priorities and budget, the information below outlines where typical shortfalls in your medical scheme may occur:

Medical scheme tariffs

When hospitalized, specialist medical practitioners are essential to the diagnosis and successful treatment. Your medical scheme will only cover practitioner fees at the stipulated medical scheme tariff.
A private specialist may charge up to 6x more than the tariff allowance. You are liable for the balance.

Gap pays the difference up to 600%.

There may be times when the majority of your bill is not covered by your medical scheme. Gap pays the difference up to 600%.


You may need an MRI or CT Scan to diagnose a potential health threat. Think it’s 100% covered? It’s not. Your medical scheme will request a co-payment from you (a fixed amount you are required to pay before certain procedures like MRI or CT scans). Please be sure to check what co-payments are imposed by your medical scheme.

Including a procedural co-payment benefit on your gap plan, to cover the co-payment up to R185 000 per person per annum.

If you hit a sub-limit, you may have to forgo further treatment unless you can cover the costs yourself.


This refers to the maximum amount that your medical scheme makes available from your plan for certain types of procedures or treatments. If you hit this limit, you may face the prospect of having to forgo further treatment. That’s not a situation anyone would want to find themselves in when fighting a life threatening illness.

Including a sub-limit cover benefit on your gap plan boosts the total levels of cover.

Innovative procedures & treatments your doctors may recommend, may be excluded from your medical cover.

Non-PMB Treatments

Your medical scheme is not required to provide cover for treatment options that do not appear on what is called the Prescribed Minimum Benefits (PMB) list. This means you may not be eligible to receive the treatments your medical specialist may recommend – such as biological drugs for the treatment of cancer.

Including a cancer cover benefit on your gap plan, provides you with access to continued innovative cancer treatments, to assist you when your medical scheme limits have been reached.

It may surprise you to discover that casualty ward expenses are excluded from hospital plan cover.

Casualty ward & out-of-hospital treatments

Hospital plans don’t cover visits to the emergency or casualty rooms as these are considered ‘out-of-hospital’. Unless the scheme offers a specific emergency benefit, the visit to the ER would be paid from your medical savings. Thus, if your medical savings are depleted, you would be paying for casualty ward expenses from your pocket.

Including a casualty cover benefit on your gap plan allows for R10 000 per family per annum for emergency treatment in the casualty ward of a hospital in the event of accidental injury. Cover is also extended for emergency after-hours treatment required for illness, at a registered medical facility, for children younger than 5 years of age.

You may not be free to choose the private hospital facility you wish to visit.

Non-designated service providers penalty

Got a dire emergency and find yourself at your nearest hospital?
Your medical scheme may demand a co-payment from you if the hospital falls outside of its network of preferred service providers.

Including a co-payment benefit on your gap plan, covers penalties up to R13 500 per family per annum.

Our gap cover plans start from
R355 p/m for the whole family

Pick your cover to meet your budget and most critical priorities.


*Prices quoted are indicative of your risk profile as defined by Medway.

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