How does Gap Cover work?

How can you plan for the unplanned using a Gap Cover Product?


Here is a simple overview of how Gap Cover works.


Gap cover works by covering the difference or shortfall between what your Doctor charges and what your medical aid pays from the Risk or hospital benefit. You might also want to know why you need Gap Cover? Depending on the option you select, you will also have cover for Medical aid Co-payments, Sub-limits and cancer treatment shortfalls. We also covered, in detail, What Gap Cover is all about.


How does gap cover and medical aid differ from one another?


Gap cover is not a replacement for a medical aid. Gap cover serves to cover shortfalls where doctors charge above medical aid rate, and where medical aid pays up to their specified rate from the Risk or hospital benefit.


Over and above this, Gap cover will also provide cover for the following areas of shortfall depending on the option you select:

  • Medical aid Co-payments
    • These are upfront
  • Sub-limits
  • Oncology shortfalls


Gap cover cannot provide cover where medical aid does not pay towards a procedure or covers the full amount for a procedure.

Medical aid serves as the primary point of health cover and will cover your stay in hospital as well as approved Medical procedures at a specific rate of cover according to the medical aid option you select. Gap cover serves to guard you in the event Doctors charge above your medical aid rate of cover and a shortfall is incurred after medical aid pays from the risk or hospital benefit.


How do you sign up for gap cover and are there any pre-requisites?


You may sign up for gap cover using the following channels:


In order to be eligible for Gap cover, you must meet the following criteria:

  • Be on a registered South African Medical aid
  • If you are on a Health Insurance and not on a medical aid, gap cover will not be applicable.


Any Dependants you wish to add onto your gap cover policy must be registered dependants on your medical aid or your spouse’s medical aid in order to be on the same gap cover policy as you.


How do gap cover claims get processed?


You will have 6 months from your date of discharge in which to submit a Gap Cover claim to Stratum Benefits.

Provided that we receive all required documentation pertaining to your claim, we will revert with feedback of approval or rejection within 7-10 working days.

Gap Cover claims are processed on a line-by-line basis according to the medical aid statement provided and counter checked with the relevant Doctor’s accounts and hospital account to identify valid shortfalls, co-payments and sub-limits.

This is cross-checked against your Stratum Policy and is assessed according to the benefits and limitations you have applicable and the waiting periods imposed per benefit.

It is imperative that before you claim you read your policy documents and familiarize yourself with your benefits, wating periods and the Exclusions applicable.

Stratum Benefits (Pty) Ltd, an authorised FSP 2111, is underwritten by Constantia Insurance Company Limited, an authorised FSP 31111. Stratum Fuel Rewards is administered by YBH Rewards (Pty) Ltd, Registration Number 2018/579872/07 in association with Shell Downstream South Africa (Pty) Ltd, Registration Number 2007/016255/07. This document is a summary and does not replace any information provided in your policy documentation. In the event of any differences, your policy contract will apply. Terms and conditions apply.