Medical Aid + Gap Cover: The Real Maths

South African specialists routinely charge 300-500% of medical aid tariff. Without gap cover, members on hospital plans can face shortfalls of R40,000 to R250,000 per major procedure. Here's the maths, the regulation and the smart way to layer the two.

How the shortfall actually arises

Medical schemes are regulated by the Council for Medical Schemes (CMS) and pay specialists at "scheme rate" - typically 100% to 300% of the National Health Reference Price List (NHRPL). Specialists are not bound by these rates. A hip replacement at a private hospital may invoice R180,000 in surgeon, anaesthetist and assistant fees while the scheme pays R65,000.

Procedure | Typical specialist invoice (R) | Scheme pays at 200% | Shortfall
Caesarean section | 52,000 | 28,000 | 24,000
Knee replacement | 165,000 | 74,000 | 91,000
Cardiac stent | 210,000 | 95,000 | 115,000
Cancer surgery + oncologist | 280,000 | 105,000 | 175,000

Gap cover - the regulatory frame

Gap cover is regulated under the Demarcation Regulations (2017) and is insurance, not medical aid. Regulation caps the annual benefit at R208,750 per beneficiary (2024), indexed yearly. Providers include Stratum, Sanlam Gap, Zestlife, Turnberry and Discovery Gap.

What gap cover actually pays

In-hospital tariff shortfalls (the big one)

Sub-limits on internal prosthesis and oncology

Co-payments on MRI/CT scans

Casualty visits for trauma (with conditions)

Cancer extender benefits beyond your scheme's annual cap

The combined-cost playbook

A family of four on a quality hospital plan (R7,200/mo) plus gap cover (R420/mo) totals R7,620/mo. The same family on a comprehensive scheme without gap pays R14,800/mo and still has sub-limits on prosthetics and oncology. The hospital-plan + gap combination consistently saves 30-45% with stronger catastrophic protection.

Common mistakes

Buying gap cover from a different provider than your scheme without confirming alignment of in-hospital event definitions.

Missing the 3-month general waiting period and 12-month condition-specific waiting on gap cover.

Assuming gap covers day-to-day GP visits - it does not.

Cancelling gap when switching schemes - waiting periods restart.