How Gap Cover Assists with Shortfall Payment

The difference between medical costs and medical aid coverage often leaves individuals vulnerable to unexpected expenses. Herein lies the significance of gap cover. This is a supplementary insurance policy designed to safeguard individuals against a shortfall payment. While it’s imperative to have quality healthcare coverage in South Africa, it helps to have additional security so you don’t have to worry about being burdened by out-of-pocket expenses for specialised treatments or hospital stays that exceed your coverage limits. Discover why a medical shortfall payment can occur and how gap cover functions as a buffer, absorbing the difference between what healthcare providers charge and what primary medical aid plans cover. For affordable healthcare options, you can get health insurance quotes that include gap cover for comprehensive protection.


What is a medical or healthcare shortfall payment?

A shortfall payment refers to the portion of medical expenses that an individual must pay out-of-pocket because it exceeds what is covered by their medical aid plan. When the cost of the medical services or treatments exceeds the coverage limit or falls outside the scope of the policy, the primary policyholder is responsible for paying the difference. This shortfall payment can arise due to various factors such as deductibles, co-payments, or services not covered by the plan. 


Shortfall payments – despite having medical aid cover 

Individuals may encounter medical shortfall payments despite being covered by their medical aid. This is due to several factors. Let’s unpack this using the following example:

Suppose Sizwe has a Momentum medical aid plan with a R15,000 annual deductible. He requires surgery that costs R150,000. Initially, Sizwe must meet his deductible before insurance coverage kicks in. So, he pays the first R15,000 out-of-pocket for the surgery.

After meeting the deductible, Sizwe’s medical aid covers 80% of the remaining costs, while he’s responsible for the remaining 20% co-payment. So, Sizwe’s policy pays R120,000 leaving him with a R30,000 co-payment.

In this common scenario, Sizwe ends up paying a total of R45,000 rand out-of-pocket despite having medical aid coverage. 


These are some of the reasons why medical shortfall payments occur:

  • Deductibles: Many medical aid plans require individuals to pay a certain amount out-of-pocket before coverage begins. This initial expense contributes to the shortfall payment.
  • Out-of-pocket maximums: Although there’s a cap on how much individuals have to pay out of pocket in a given year (the out-of-pocket maximum), reaching this maximum can still result in co-payments. 
  • Non-covered services: In some instances, medical aid plans may exclude certain treatments, medications, or services from coverage altogether. In these cases, individuals are responsible for the full cost.
  • In-network vs. out-of-network: Using services from out-of-network medical providers can result in higher out-of-pocket expenses due to reduced coverage. Individuals might have to pay the difference between what the out-of-network provider charges and what their insurance covers. 

The way Gap cover assists with shortfall payments


A gap cover policy is designed to address the discrepancy between the fees charged by healthcare providers and the coverage provided by the primary healthcare plan. It is a supplementary insurance policy that assists policyholders in reducing their out-of-pocket expenses for medical treatments and services that exceed the limits of their primary medical aid cover. Typically encompassing services such as specialist consultations, surgeries and hospital stays, gap cover serves to bridge the financial disparity between healthcare provider charges and medical coverage, providing individuals with comprehensive financial healthcare protection


The benefits of gap cover include: 

  • Reduced out-of-pocket expenses: Gap helps reduce the financial burden of medical treatments by covering the difference between the primary healthcare coverage and the actual medical costs. This reduces out-of-pocket expenses, including those related to deductibles and co-payments.
  • Access to better healthcare providers: With gap cover, individuals have access to a wider network of healthcare providers, including specialists and hospitals that might charge higher fees. This ensures that patients can choose the best medical care available. 
  • Affordability: Gap cover premiums are very affordable, especially considering the potential financial benefits and peace of mind it provides. 

Moreover, gap cover offers a broader scope, including services such as specialist consultations, surgeries, and hospital stays, which may not be fully covered by the primary medical aid plan. This allows individuals to focus on their health without worrying about the financial implications. 

Bloom Financial Services offers two types of gap cover plans to suit your needs and budget. These include:

  • Gap Core: the affordable answer to unexpected medical expenses. The plan offers in-hospital coverage at affordable premiums. 
  • Gap Max: provides a more comprehensive cover, including tariff shortfalls, upfront payments and co-payments. 

Get Gap cover for added medical financial security

Medical shortfall payments occur even with comprehensive medical aid coverage due to factors like deductibles and non-covered services. Understanding these factors in your policy is crucial for individuals to anticipate and budget for their healthcare expenses effectively. Get gap cover together with your medical aid plan for you and your family members, and ensure greater financial protection against unexpected medical expenses. Contact our offices to speak with a trained consultant to discuss your options. 


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Momentum Health4Me is not a medical scheme product, and is not a substitute for medical scheme membership. The information provided on this website does not constitute advice in terms of the Financial Advisory and Intermediary Services Act. Momentum is a division of Momentum Metropolitan Life Limited, an authorised financial services provider (FSP 6406) and a wholly owned subsidiary of Momentum Metropolitan Holdings Limited.

Bloom Gap Cover is not a medical Scheme. Products that are offered are not the same as that of a medical scheme.

© Bloom Financial Services 2023. Bloom Financial Services (Pty) Ltd is an authorised financial services provider (FSP 50140). Bloom Gap is underwritten by Infiniti Insurance Limited a licensed non-life insurer and an authorised financial services provider (FSP No.35914)

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