About Gap Cover

Gap cover is a short term insurance product that provides cover for:

• The Principal member and immediate dependants that are registered as dependants on the Principal member’s South African Registered Medical Scheme.
• Service providers such as specialists, surgeons, anaesthetists etc. who charge in excess of the medical scheme tariff for authorised in-hospital procedures and specified authorised out of hospital procedures.
• Limited to five (5) times the Medical Scheme tariff less the higher of the Medical Scheme Tariff or the Medical Scheme Option Reimbursement Rate
• Out-patient chemotherapy, radiotherapy and kidney dialysis
• Hospital co-payments
• Sub limit cover

As a member of a Private Medical Scheme, you would expect that an event in-hospital would be covered in full, this is not so. Most Medical Schemes will cover in-hospital expenses defined as services rendered by a Medical Practitioner at the Medical Scheme rate. However, most Specialists today are charging rates that are substantially higher than the Medical Scheme rates and you, as the member are liable for the difference, this is known as the tariff gap.

The Ambledown Gap Cover Series is an Insurance Product that provides cover for you and your immediate family for the shortfall (Gap) resulting from any Medical Practitioner charging above the Medical Aid Tariff for in-hospital surgical procedures and certain out of hospital procedures. The insured will receive a benefit equivalent to the costs incurred as a result of the Gap for any hospital admission as an in-patient. The Gap is defined as services rendered by a Medical Practitioner who charges above the Medical Scheme tariff. .

View our gap cover products

Gap cover does not cover the following:

• Charges above the Medical Scheme tariff for hospital costs and medication, e.g. cost of bed, food, bandages etc.
• Any procedure not covered or declined by the Medical Scheme.
• Any PMB (Prescribed Minimum Benefits – charges  which should be provided for by the Medical Scheme, this includes ward fees and theatre stock charges)
• Split billing.
• Short falls or penalties related to the use of an non-DSP or out of network provider.
• Day to day expenses once the medical savings account has been depleted.
• No benefit provided on the medical aid option.
• Extended family members who are dependants.

Please refer to the master policy document for the full list of exclusions.

Who will not be covered in your gap cover policy? 

• Parents
• Relatives
• Children that are:
• age 21 or older
• age 26 or older even if the child is unmarried, fully financially dependent on the Principal and a dependant on the Principal member’s medical aid

NOTE: Any parent, relative or child that is not covered under the Principal member’s gap cover can take out their own gap cover provided they belong to a South African registered Medical Scheme.

Ambledown is a leading health insurance product provider in South Africa. Our Ethics: It is our fundamental nature to avoid products that reside in the “grey” areas of the law, we do not look to exploit legal technicalities or find creative “loopholes” in legislation.