02 Mar Top 5 questions to ask your GapCover provider

GapCover can save you by not leaving you stuck with bills you thought were covered.

Choosing GapCover can feel simple at first. Many new medical scheme members in South Africa assume these products work in the same way and offer similar benefits. But in reality, the fine print makes a difference.

If you’re a new medical scheme member, or even just reviewing your cover, these five questions will help you avoid costly surprises. Get them right, and you’ll know exactly what you’re paying for.

1. What medical scheme tariffs does this GapCover align to?

Why tariff alignment matters

Medical schemes pay claims according to set rates, often referred to as medical aid rates or scheme tariffs. Specialists and hospitals may charge more than these rates. The difference between what your scheme pays and what the provider charges is known as a tariff shortfall.

GapCover is designed to assist with these shortfalls, but only when it aligns correctly with the tariff your medical aid uses. If this alignment is unclear, you may still face out of pocket medical costs for in-hospital procedures.

Ask your broker:

• What tariff does my medical aid use?
• How does this GapCover calculate benefits in relation to that tariff?

Knowing this helps you avoid the classic “I thought that was covered” moment after a hospital visit.

2. Does the GapCover include co-payments and in hospital shortfalls?

Where unexpected costs usually appear

Co-payments are fixed amounts you must pay for certain procedures, tests, or specialist care. Many happen in-hospital, where people assume everything is covered. However, not all GapCover options include co-payment cover. Some do. Some don’t.

With GapCover Combined cover, you are covered for these co-payments.

Ask your broker:

• Are both co-payments and shortfalls covered?
• Is it just procedure-related co-payments, or others too?

This tells you how the product works in real-life. Not just on paper.

3. What benefit limits apply per year and per claim?

Understanding how limits affect real claims

Every GapCover option has benefit limits. These limits may apply per year, per claim, or both. A high annual limit can sound reassuring, but it is important to understand how quickly that limit could be reached if more than one claim occurs in a year.

Ask your broker:

• What is the maximum benefit per claim?
• How does the annual limit apply if I need more than one procedure?

Your life stage matters here. A single young professional may have different healthcare needs from a young, growing family. Understanding limits helps you assess whether the product suits your likely medical use.

4. Are there exclusions or conditions I should know about?

Why reading exclusions protects you later

Every GapCover option has benefit limits. These limits may apply per year, per claim, or both. A high annual limit can sound reassuring, but it is important to understand how quickly that limit could be reached if more than one claim occurs in a year.

Exclusions may include:

• Specific treatments or procedures
• Pre-existing conditions
• Waiting periods (yes, sometimes up to 12 months)

Ask your broker:

• Can you explain exclusions and waiting periods in plain English?
• How might they affect me personally?

Read this blog to find out more about GapCover’s exclusions.

5. How does this GapCover work with my current medical aid?

Fit matters more than features

GapCover works alongside your medical aid. It doesn’t replace it. How effective it is depends on how well it aligns with your specific medical aid option and benefits.

Different medical schemes have different benefit structures, co-payments, and limits. These factors affect how the product applies in practice.

Ask your broker:

• Is this product suitable for my medical aid option?
• How are claims processed between my medical aid and this GapCover?

If your cover doesn’t integrate with your scheme, you’re likely paying for gaps that still leave you… well, with gaps.

From questions to confident next steps

GapCover is about helping you make informed decisions, not rushing you into purchasing a product. By asking the right questions upfront, you take control of your healthcare and finances.

Start with your medical aid. Review your risks. Then use these five questions to filter GapCover options that truly fit your life.

Not sure where to begin? Contact GapCover and we will help you find the best fit.