If you think Gap Cover is just another insurance policy, think again.

With Stratum Benefits Gap Cover, you get an insurance policy that’s not only affordable but gives peace of mind knowing that you’re covered when you need it most. Yes, as insurance policies go, we too have waiting periods and benefit exclusions but the proof of the pudding is in the fact that in most cases this insurance policy will pay out more in benefits than what you’ll ever pay in premiums.

Don’t take our word for it. Ask any of our clients.

Gone are the days where Gap Cover was a nice-to-have policy. Just looking at what we pay out in claims and the increase in frequency of claims per policy, it’s safe to say that nice-to-have is out, and must-have is in.

What is Gap Cover? In a nutshell, it’s a short-term insurance policy that’s mainly designed to cover the difference in your doctors’ and specialists’ fees that your medical aid plan doesn’t cover in full. For Gap Cover to work, you need to be a member of a registered South African medical aid.

Noticed that we said “mainly”? That’s because Gap Cover offers so much more than just covering the shortfalls on medical bills.

Does your medical aid cover your healthcare providers fees in full? You wouldn’t be the only one wishing so but as great as your medical aid plan’s benefits might be, it’s not always enough.

Here’s why…

Medical aids pay healthcare and service providers’ accounts at a specific medical aid rate that can vary from 100%, to 200% or 300%, depending on the medical aid plan you’re on.

If your specialist is contracted to your medical aid, you shouldn’t have any shortfalls because your medical aid will pay your specialist at the agreed medical aid rate. But, if your specialist isn’t contracted to your medical aid, they’ll most probably charge private fees and you’ll be responsible to pay the difference after your medical aid has settled a portion. How’s that working out for you?

Let’s say your specialist charges R 1 500 for a medical procedure of which your medical aid pays R 1 000. You’ll be left with R 500 to pay from your own pocket. That doesn’t sound too bad, right? Perhaps R 500 here and there isn’t anything to lose sleep over, but will R 5 000 keep you up at night?

Let’s paint a more realistic scenario.

You go for joint replacement surgery.

Your medical aid plan covers you at a 100% of medical aid rate.

The hospital bill is covered in full because the hospital charges in line with your medical aid’s rate. Phew!

Your orthopaedic surgeon, however, charges 400% above your medical aid’s rate.

But wait, there’s more… because the anaesthetist charges 300% above your medical aid’s rate.

Get it? Your surgeon charges 4 times more than your medical aid plan’s rate and the anaesthetist charges 3 times more. It’s not uncommon for surgeons and anaesthetists to charge these rates, but the question is – can you afford these kinds of shortfalls?

When assessing claims, we look at each line item on every provider’s account to determine where the shortfalls are. As painted in the scenario above, your surgeon and anaesthetist charges private fees which your medical aid won’t cover in full.

Being covered on the right Gap Cover option could mean no shortfalls to worry about, and no dipping into your savings to pay outstanding medical bills. How cool is our cover? Way cool 😉.

Here’s a quick calculation.

Total cost of surgery Your medical aid pays @ 100% of medical aid rate What you’ll be liable for without Stratum Benefits Gap Cover
Orthopaedic Surgeon R 24 000.00 (Charged at 400% above medical aid rate) R 4 800.00 R 19 200.00
Anaesthetist R   6 000.00 (Charged at 300% above medica aid rate) R 1 500.00 R   4 500.00
Total R 30 000.00 R 6 300.00 R 23 700.00


What’s on offer? Our Gap Cover options provide cover at an additional 300% or 500% over and above what your medical aid plan provides.

Let’s say you’re an individual aged 64 or younger covered on our 500% Elite Gap Cover option at R 376 per month. If this premium never increases, it will take you approximately 5 and a half years to make up in premium what we’ve paid towards the cost of your joint replacement surgery. Oh, did we mention that our Elite Gap Cover option would’ve covered your shortfall in full? Talk about bang for your buck!

What else does R 376 per month cover you for? A whole lot!

You’ll also benefit from our Co-Payment Cover that refunds various co-payments and deductibles imposed by your medical aid. You know… those upfront amounts your medical aid wants you to pay before being admitted to hospital or before having a scope or scan done. Nasty little things, aren’t they?

Did you have to pay a co-payment before going for joint replacement surgery?

And what about the internal prosthetic device that you needed as part of your joint replacement surgery? Did your medical aid cover it in full? Our Sub-Limit Cover can help up to the benefit limit provided by your chosen Gap Cover option.

Needed a follow-up visit to the specialist after your surgery? That’s what our Out-Patient Specialist Consultation Cover benefit is for.

And that’s just mentioning three benefits our Elite Gap Cover option offers.



Gap Cover is an after-the-fact kind of policy. For it to work, your medical aid must first make payment from your medical aid plan’s risk or hospital benefit before we can do out bit. We can’t predict what your medical aid will or won’t pay so we can’t pre-authorise upcoming medical events, or give guarantees that shortfalls will be covered.

That’s why, when claiming, you’ll need to submit copies of all the healthcare providers’ accounts, and a copy of your medical aid’s claims transaction history to show what your medical aid paid towards each line item on the relevant healthcare providers’ accounts.

Approved claim amounts will be paid directly to you to reimburse your healthcare provider with. If your healthcare provider grants us a discount on the amount owing, we’ll pay them directly. Simple.

Submitting a claim is easy, and you’ll have plenty of time to get the paperwork ready – 6 months from the date of your medical event. Simply complete our editable Gap Cover Claim Form and email it to us, or submit it online. Our standard turn-around time to assess claims, if all the required documents have been submitted, is 7 – 10 working days.

Want to sign up? Of course, you do!

Get in touch with your financial advisor or give our Client Service Centre a call. We’re standing by!