Gap Cover Calculator
Calculate your medical aid shortfall and how much gap cover pays. Compare gap cover plans for common SA hospital procedures.
Quick Calculator Get a fast estimate
R
R
Out-of-Pocket Cost
R 0
Specialist Charge
R 12 000
Medical Aid Pays
R 3 500
Gap Cover Pays
R 8 500
Total Shortfall
R 8 500
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How Gap Cover Works
Specialist charge = R12,000. Medical aid tariff = R3,500 at 100% = scheme pays R3,500. Shortfall = R8,500. With gap cover at 3× tariff: R3,500 × 3 = R10,500 max payout, covers the full R8,500 shortfall. Out-of-pocket: R0 vs R8,500 without gap cover.
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Extended Calculator More options, charts, and scenario comparison
R
R
Per Visit Analysis
Out-of-pocket: R 0
Scheme pays
R 3 500
Shortfall
R 8 500
Gap (plan 1)
R 8 500
Typical Specialist Charge Rates in SA
| Specialist Type | Typical Charge | % of Tariff |
|---|---|---|
| General Surgeon | R 5,000–R 15,000 | 200–400% |
| Orthopaedic Surgeon | R 15,000–R 50,000 | 300–500% |
| Cardiologist | R 10,000–R 40,000 | 300–500% |
| Anaesthetist | R 5,000–R 20,000 | 250–450% |
| Gynaecologist (delivery) | R 12,000–R 35,000 | 300–500% |
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Professional Calculator Complete parameters, sensitivity analysis, and detailed breakdown
Common SA Procedures — Shortfall Analysis
| Procedure | Specialist | Scheme Pays | Shortfall | Out-of-Pocket |
|---|---|---|---|---|
| Appendectomy | R 28 000 | R 8 500 | R 19 500 | R 0 |
| C-section | R 32 000 | R 9 200 | R 22 800 | R 0 |
| Hip Replacement | R 85 000 | R 22 000 | R 63 000 | R 0 |
| Knee Arthroscopy | R 22 000 | R 6 500 | R 15 500 | R 0 |
| Spinal Surgery | R 65 000 | R 18 000 | R 47 000 | R 0 |
| Cardiac Stent | R 48 000 | R 14 000 | R 34 000 | R 0 |
| Hysterectomy | R 38 000 | R 11 000 | R 27 000 | R 0 |
| Cataract Surgery | R 14 000 | R 4 500 | R 9 500 | R 0 |
Gap Cover Plan Comparison
| Plan | Monthly/member | Annual Premium (2 members) | Multiplier | Max Benefit |
|---|---|---|---|---|
| No Gap Cover | — | — | — | — |
| Essential | R 260 | R 6 240 | 3× tariff | R 150 000 |
| Comprehensive | R 385 | R 9 240 | 5× tariff | R 250 000 |
| Premier | R 430 | R 10 320 | 6× tariff | R 300 000 |
Important: Gap cover is short-term insurance, not medical aid. It covers the difference between what your medical aid pays and what specialists charge. Gap cover does not cover co-payments, deductibles, or non-medical-aid-registered costs. Specialist rates in SA commonly run at 300–600% of the medical aid tariff.
Frequently Asked Questions
Take out gap cover when you join medical aid or at the start of a new year — there are no late joining penalties like medical aid, but some plans have a 3-month waiting period for elective procedures. Gap cover is most valuable for anyone with a medical aid plan that pays 100–200% of tariff who visits specialists regularly.
Gap cover premiums are not included in the medical aid tax credit, but payments received from gap cover for qualifying medical expenses may be deductible as out-of-pocket medical expenses (Section 6B). Consult a tax practitioner for your specific situation.